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Won t Happen in My Office! Systemic Emergencies in Optometric Offices Richard Meetz, OD, MS, FAAO Todd Peabody, OD, MBA, FAAO Disclosure Statement: Nothing to disclose Please complete your session evaluation
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Won t Happen in My Office! Systemic Emergencies in Optometric Offices Richard Meetz, OD, MS, FAAO Todd Peabody, OD, MBA, FAAO Disclosure Statement: Nothing to disclose Please complete your session evaluation using EyeMAP online at Tweet about this session using the official meeting hashtag #aaoptom14 Please silence all mobile devices. Unauthorized recording of this session is prohibited. What are you going to do! Emergencies This course will discuss the presentations of some of the more likely in office emergencies associated with systemic conditions ranging from: Hypertensive crisis Heart attack Stroke Seizures Anaphylaxis The endocrine crises Hypoglycemia Levels of Action Immediate action Stat Immediate in office care (IC) After the immediate in office care, what next? Emergency care (EC) 2 hours Urgent care (UC) 48 hours Follow-Up care (FC) 2 weeks (1-2 weeks) Home care (HC) Hypertensive crisis 1 Hypertensive Emergencies JNC 7 Blood Pressure Classification Definition: Hypertensive emergencies and urgencies occur with blood pressures greater than 180/120 mmhg Stage 2 HTN : JNC-7 FYI: JNC-8 for treatment 1% of population 24% of ER visits BP Classification Normal Prehypertension Stage 1 Hypertension SBP mmhg and or or DBP mmhg Stage 2 Hypertension 160 or 100 Hypertensive crisis Hypertensive crisis Hypertensive crisis occur with blood pressures greater than 220/120 mmhg 0.04% of population 3% of ER visits At DSP 120mmHg, BBB is compromised leading to brain edema Hypertensive crisis Malignant Hypertensive (MHTN) AKA Hypertensive Emergency with Papilledema Occurs at blood pressures typically at 220/140 mmhg or more with papilledema 14% of ER HTN crisis visits or 0.42% of ER visits Approx 0.005% of population Papilledema is an indication of brain swelling DSP 120 mmhg MHTN Terminology not currently used Hypertensive Emergency with papilledema Currently all BP 160/ 100 are listed as Stage II JNC-7 44 yo W female, CC a stye & spots in her vision Hx: Neg HTN, No meds VA: 20/20+ OD, 20/50- OS NIPH Ext: Mod hordeolum, PERRL neg APD BP: 240/150 mmhg Rt arm DFE: AV severe narrowing, pos AV nicking Case 2 58 yo W female, CC near blur Hx: +HTN 10 years, + meds poor compliance VA: 20/20 OD,OS,OU BP: 220/120 mmhg Rt arm Another Case Hypertensive crisis What do you do? Who goes to the ER? Who sees their PCP tomorrow? Who sees their PCP next week? DFE: AV generalized narrowing, positive AV nicking Referral Criteria BP 180/110 Severe Hypertension Mild HTN retinopathy (AV & nicking) Call PCP; BP controlled in 3 to 7 days Cardiac Emergencies BP 180/120 Hypertension Urgency Moderate HTN retinopathy with HA or peripheral edema Call PCP or walk in clinic; BP controlled in 24 to 72 hours BP 180/120 Hypertension Emergency Papilledema with moderate HTN retinopathy ER/ICU; BP reduced 20% in 2 hours, ICU 4 days Definitions Sudden Cardiac Death = sudden, unexpected death caused by loss of heart function (sudden cardiac arrest) Leading cause of natural death in the US Most are caused by arrhythmias Most common life-threatening arrhythmia is ventricular fibrillation Cardiac Arrest = electrical problem; heart stops beating Heart Attack = circulation problem; blood flow to heart is blocked Definitions Acute Coronary Syndrome = umbrella term of symptomatic conditions resulting in an inadequate blood supply to the heart Acute myocardial infarction (AMI) Circulation problem Different from sudden cardiac arrest, but may cause arrest Unstable angina Blood clot causes a reduced blood flow, but not a total blockage 3 Heart Attack Triggers Most AMI occur at rest or with modest activity (85%) Emotional stress and life events Illicit drugs Warning Signs / early symptoms of AMI Chest discomfort Sweating Nausea & vomiting Shortness of breath (SOB) Heart Attack Classic warning sign of AMI is chest discomfort (males) Warning Signs of AMI Chest discomfort Heart Attack Different in women, elderly and diabetics Women: back pain (between shoulder blades), diffuse chest pain or GI Diabetics & elderly: increase weakness, SOB, syncope AHA Musculoskeletal pain Heart Attack Sharp or twinges of pain are usually - NOT an AMI Pain reproduced by pushing on spot - NOT an AMI Unstable angina Angina lasting less than 15 minutes - NOT an AMI Angina at rest - think AMI Angina is not relieved by 3 nitroglycerin tabs in 10 min - think AMI Heart Attack Emergency action plan (for person with unknown ACS) 1) Recognize the Signs & Symptoms 2) Have the patient stop activity and sit or lie down 3) If symptoms persists 5 min, call 911 4) Give patient an ASA and administer Oxygen 5) Be prepared to provide CPR 4 2013 CPRed 11/11/14 team solo Basic Life Support Guidelines adult child infant 100 CPM compressions to breaths 30:2 30:2 30:2 30:2 15:2 15:2 depth of compressions 2 at least about 2 1/3 depth of chest rescue breathing 1per 6 seconds 1per 4seconds 1per 4seconds early AED early CPR early CPR + BLS for Healthcare Providers American Heart Association CPR classes See or call Heart Attack Emergency action plan (for person with known ACS) 1) Recognize the signs & symptoms 2) Have person stop activity and sit or lie down 3) Give one nitro tab q 3 to 5 min for up to 15 min or 3 tabs If symptoms persist, call 911 4) Give person an ASA PO and administer Oxygen 5) Be prepared to provide CPR Heart Attack Denial of an Heart Attack Victims frequently deny the possibility of having an AMI It s indigestion or something I ate It can t happen to me, I m too young/healthy I ll go home an rest or take something when I get home I don t want to bother anyone/doctor I can t afford to go to the doctor or hospital I ll feel foolish if it is nothing Heart Attack Final advice on in-office heart attacks Be ready to act! Time matters Know CPR and keep it current Have your staff trained and current The next victim may be you Heart Attack Time to Treatment Impact on Survival Stroke AHA 5 Stroke Definition: A general term for the sudden onset of a focal neurologic deficit caused by vascular disease lasting greater than 24 hours with lasting effects 54 yo male Pack per day smoker x 35 years Hx: HTN (stage 1); questionable compliance with meds Sx: facial weakness, slur/speech difficulty, eyelid drooping, double vision x 4 days Case M.Zatouroff History and External Exam Your history s most important questions: Time of onset! Progression External examination next most important steps: Check for abnormal speech Check for facial droop Check for arm drift Check for abnormal gait Clinical Presentation of Stroke Intense or unusually severe HA of sudden onset Altered level of consciousness Aphasia Incoherent or difficulty understanding Dysarthria (slurred speech) Facial weakness or asymmetry Visual loss, double vision, intense photophobia Systemic Findings of Stroke Incoordination Weakness, paralysis, or sensory loss of one or more limbs Ataxia Vertigo, nausea, vomiting, phonophobia Clinical Presentation of Stroke Evaluation of acute stroke: Ask patient to smile & raise eye brows then close eyes AHA Pearls: Does forehead wrinkle? Can close eyes? 6 Stroke Evaluation of acute stroke: Conduct the arm drift test: eyes closed arms out hold level AHA Stroke Risks Age: males 45 or females 55 Females post menopause or S/P H&O any age Family Hx: parents, grandparents or sibling with stroke African Americans, Hispanics or Asian-Pacific Islander groups Smoker or live with a smoker Blood pressure over 140/90 Overweight by 20 lbs (BMI 30) Physical activity 30 minutes daily Diabetic Stroke Risks Total Cholesterol is 240 HDL less than 35mg/dL Hx of TIAs in past year Hx of carotid artery disease Coronary heart disease, atrial fibrillation or past MI Peripheral vessel Dz ( legs) Polycythemia or Hct 60% Stroke Risks in Young Adults HTN Oral contraceptives Metabolic Dz / Hypercoagulable states Binge/high alcohol consumption HTN, Intracranial, cerebral infarction Increased risk of death Drug use: Cocaine abuse Subarachnoid, intracerebral, cerebral infarction Amphetamine Intracranial speed hemorrhage Stroke Types: 1) Infarction (ischemic injury) w Thrombotic (clot within a vessel) w Embolic (vessel blockage) w Lacunar (small vessel Dz) w DM and HTN 2) Hemorrhage (clot outside vessel) Types of Strokes 7 Thrombotic Stroke Blood clots within a vessel Occurs during sleep or is present on awakening Symptoms & signs progress in a stepwise fashion May take hours to days for the full deficit to develop Vision symptoms are common Embolic Stroke Caused by material formed proximally, then dislodged to occlude a distal vessel Carotid most common Cardiogenic emboli 15 to 20% Most often occurs during waking hours No warning signs Display maximal deficit at onset Deficit may improve in hours Subarachnoid Hemorrhage Sudden onset of severe HA with activity Worst HA of my life Stiff neck and photophobia at onset Altered level of consciousness (stupor to coma) Nuchal rigidity (neck rigidity) Bloody CSF Vomiting, fever, seizures 40% of aneurysms give positive warning sign A sentinel hemorrhage Intracerebral Hemorrhage AKA: Primary hypertensive hemorrhage Most always occurs secondary to sustained elevated systolic blood pressure Onset awake & active No prodrome 50% report severe HA Subdural & Epidural Hemorrhage No prodrome Most often secondary to trauma or aneurysm Associate with HTN 50% report severe HA as stroke evolves in the 1 st hour High fatality 50% of those who survive the 1st 24 hrs will die within 2 weeks Stroke Differential: TIA TIA = Transient Ischemic Attack TIAs are a symptom of a disease, not a specific disorder Definition: Acute neurologic deficit of vascular origin Clears completely ( 24Hr) Lasts minutes to an hour If 30 min usually 2 to infarct 8 Stroke Differential: RIND RIND = Reversible ischemic neurological deficit Definition: Transient deficits lasting more than 24 hours but clearing completely in a few days Should improve within 3 days May take up to two weeks Stroke Warnings 1/4 of patients with TIAs will have a stroke within 3 years TIAs & RINDs 1/3 will have a stroke within 5 years Positive history of TIAs in 1/2 to 2/3 of patients with thrombotic strokes Stroke Warnings TIAs & RINDs Keep in mind: A patient is more likely to have a stroke after a few recent TIAs than after TIAs occurring over a year ago Other Stroke Differentials Transient global amnesia (TGA) In older patients Focal seizures Chronic subdural hematomas Unruptured cerebral aneurysms Complex Migraines Other Stroke Differentials Lancet Score Complex Migraine M. Samuels Patients with TIA signs & symptoms need medical F/U to determine the risk and urgency of medical treatment. The Lancet ABCD scoring system for risk uses the following: Age Blood pressure Clinical features Duration Lancet ABCD scoring system Lancet Score Age 60 +1pt. Blood pressure 140/90 +1 Clinical features Weakness one side (face arm or leg) +2 Difficulty speaking or understanding +1 Duration One hour or more +2 10min but less than Score of 6 or greater = 31% risk of stroke within one week; call PC for referral 24hr Stroke Time is of most importance 85% of strokes are ischemic Fibrinolytic therapy (tpa) can be used to break up the clots 30% complete recovery Must be started no later than 4 hours after Sx onset Maybe effective up to 6 hours Action If symptoms 4 hours, call 911 Hold any HTN medications If ischemic, give an ASA Who had a stroke? XX Seizures Case 38 yo W female, CC routine eye examination Hx: Seizure Disorder Epilepsy since teenager, last episode 5-6 years ago, Meds: Clonazepam good compliance Mental Status: Ox3 VA: 20/20 OD,OS,OU Ext: WNL, PERRL neg APD, morbidly obese BP: 130/85 mmhg Rt arm, HR 80 During SLEx, patient developed SOB and became uncomfortable.pushed the lamp away.went rigid Seizure Disorders Historic term: epilepsy Note: Having one seizure or if episodes are associated with a toxic withdraw it is not epilepsy Epidemiology Most common of the neurologic disorders Estimated 4 million persons in U.S. 1 in 10 persons will have a seizure some time in their life 3% of population have chronic recurring seizures 10 Types of Seizures ILAE 1989 Historic Term Current Classification 1. Focal Simple partial seizure 2. Psychomotor Complex partial seizure 3. Jacksonian Myoclonic seizure 4. Petit mal Absence seizure 5. Drop attack Atonic seizure 6. Grand mal General tonic-clonic Tonic-clonic Seizures Prodome Patient often has a feeling something is wrong or Not feeling right today Higher risk with brain idling Seizure 2 phases 1 st : Tonic phase Rigid arched back, lasting 30 sec 2 nd : Clonic phase Rapid muscle jerking, fast at 1 st then slowing 2 min Tonic-clonic Seizures Postictal Sx: Amnesia for seizure events Deep sleep ~ 1 hour Confusion after sleep: lasts few minutes to 1 hour Focal weakness in an extremity Todd s paralysis Pseudoseizures & Other Non-seizure Disorders Benign Febrile Convulsions Infants and children (6 mos to 4 yo) Rapid rise in temp 1-4 hours to 102 Hysterical conversion reaction Drop attack a slump to the floor without injury May have convulsion-like movements Reaction to stressful event or idea Pseudoseizures & Other Non-seizure Disorders Postural hypotensive convulsion (orthostatic) The most common pseudoseizure 2 to syncope/vasovagal Brief 2-5 second myoclonic jerking Set off by sudden large drop in blood pressure 50/25 mmhg range First Aid for Seizures Keep area clear of sharp objects Observe and record Do NOT use padded tongue depressor Status epilepticus: seizure lasts for over 5 min or no regaining consciousness between CALL 911 After, check blood pressure & blood sugar Upon recovery Do not allow patient to drive home Notify PCP 11 First Aid for Seizures If postictal confusion present, don t touch or restrain the patient Give them something to do with their hands to focus their attention If patient has a known seizure disorder and is on medication, immediate medical attention is not needed Call PCP Report seizure to family and suggest medical follow up Case: Disposition Seizure Got the patient to the floor, supine, padded her head, moved stool and waste can out of area Seizure lasted 30 sec Postictal Sx: Amnesia for seizure, very confused, very sleepy Released in care of family (husband) Notified PCP Case Anaphylaxis 49 yo male, Walk in Hx: On his way into clinic via Motorcycle, took a bee in bare chest at 45 mph. Made it to waiting room. Mental Status: Ox3, Anxious External: lips swelling, hives/rash on chest Respirations: rapid, wheezing? Hypersensitivity Reactions Type I = Immediate Model: anaphylaxis Type II = Cytotoxic Model: transfusion reaction Type III = Immune Complex Model: SLE Type IV = Cell Mediated Model: TB test, poison ivy Urticaria in Drug Reactions Urticaria Large oval-annular pink wheals with white central area Transient; resolve in few hours then reappear Less common; Target lesions with red centers Palmar target rash 2 to penicillin reaction T.Habif, et al 12 Anaphylaxis Findings: Hives (urticaria) and angioedema Respiratory mucosal edema Bronchospasm Shock (cardiovascular collapse) Gastrointestinal edema Mechanism Upper respiratory tract mucosal edema Lower respiratory tract mucosal edema Symptom Nasal congestion Sneezing Coryza Tongue swelling Hoarse/loss of voice Lump in throat Cough Stridor Respiratory distress Mechanism Symptom Mechanism Symptom Dermal edema Itching (histamine) Urticaria Angioedema Bronchospasm Chest tightness Wheezing Shortness of breath Increased vascular permeability Dizziness Syncope Cardiovascular collapse GI mucosal edema Nausea Increased Gut Motility Vomiting Diarrhea Anaphylaxis Criteria Anaphylaxis: Common causes Insect stings (Hymenoptera) Foods (peanuts, tree nuts, fish, shellfish) Drugs ASA; antibiotics, especially PCN and cephalosporins (3-5%); NSAIDS( 1-3%); antineoplastic drugs Allergy shots (immunotherapy) Radiocontrast media (25-35%) Exercise (alone or with eating) Latex Blood transfusions Idiopathic (20-40%) 13 Anaphylaxis Risk Factors Atopic & allergic history, especially asthma IV vs. oral exposure Frequency and intensity of previous exposure Previous history of anaphylaxis Phases of Anaphylaxis Two phases of Type I 1. Immediate phase Within 5-60 minutes of exposure Occurs in a previously sensitized person Preformed mediators 2. Late phase May occur 2-72 hours after exposure Average 10 hours Watch patient for 8-24 hours In the Event of Anaphylaxis Action: Early recognition and accurate diagnosis Be prepared to administer epinephrine (EpiPen) Call 911 Monitor vital signs (HR, BP, respirations) Q 5 min. Heart rate (HR) will increase significantly with epi Be prepared to do CPR Overview of IC Treatment Epinephrine Oxygen Positioning of patient IV fluids Antihistamines Inhaled beta 2 agonists Corticosteroids Record vital signs Epinephrine The most important step in the emergency treatment of anaphylaxis Reverses hypotension & bronchospasm Peripheral vasoconstriction Bronchial smooth muscle relaxation Reduction of vascular permeability Epinephrine EpiPen /Epipen Jr. (Pediatric dose) Patient can self administer Shelf life ~ 2 years Premeasured; easy to use: 1) Remove cap 2) Jab into outer thigh 3) Hold firmly for several seconds Meetz 14 General Info about Epinephrine Safe during pregnancy Should/Must have epi available in your office if prescribing oral medicines Inform patient of side effects! May resemble anxiety Palpitations Shaky and/or jittery Chest pain (coronary vasoconstriction) Cool, clammy (peripheral vasoconstriction) Antihistamines Effect is not immediate Continue for 3-10 days Side effects include drowsiness even non-sedating varieties Corticosteroids Does NOT treat acute anaphylaxis May prevent biphasic reaction Lack of randomized controlled trial evidence to suggest that steroids reduce the incidence of biphasic anaphylactic reactions Emerg Med J June 2014 Rx: Prednisone 50 mg po qd x 4 days Case Disposition Epi pen administered STAT EMS contacted STAT Supplemental Oxygen provided at 6L/min Respirations: eased with-in 3-5 minutes Care turned over to EMTs upon arrival at 12 minutes S/P Anaphylaxis Aftercare Beware of the late phase May occur hours later (2-72 hours after exposure) Make sure patient has an Epipen Rx: renew every year Long acting antihistamine Referral to allergist Medic Alert bracelet Hypoglycemia 15 Case 19 yo W female, CC routine CL eye examination Hx: IDDM 5 years, Meds: NPH bid good compliance Mental Status: Ox3, Anxious, shaky & sweaty 8:20 AM late for appointment ran to clinic VA: 20/20 OD,OS,OU BP: 100/60 mmhg Rt arm, HR 100 Respirations: rapid Hypoglycemia Case presentation: unresponsive type 1 diabetic Is it Hypoglycemia? Is it Hyperglycemia? Is it Vasovagal reaction to tonometry? IOP: patient had become lethargic and uncooperative. Hypoglycemia Definition = Low blood sugar (RELATIVE!) With appropriate associated symptoms Usually more serious in the short term than hyperglycemia Low blood sugar can lead to coma, seizures and death fairly quickly Whereas hyperglycemia is usually slow-developing Hypoglycemia Low plasma glucose levels: 60 mg/dl after 12 hr. fast or 50 mg/dl OGTT or 45 mg/dl for females after 72 hr. fast 55 mg/dl for males after 72 hr. fast Clinical Hypoglycemia Glucose counter-regulation thresholds At BG below 81 mg/dl; insulin is decreased At 65 mg/dl; counter-regulation of glucagon then epinephrine occurs At 60 mg/dl; growth hormone (GH) and cortisol start (2 hour delay in effect) Symptoms occur at 54 mg/dl and cognitive changes are noted at 47 mg/dl Major CNS symptoms may not occur until 20 mg/dl Hypoglycemia Fast drop: Neurogenic Catecholamine release symptoms (adrenergic) Sweating Shakiness Anxiety Palpitations Weakness Tremor Hunger Faintness Tachycardia 16 Hypoglycemia Slow drop: Neuroglycopenic Symptoms Hypoglycemia Induced Hypoglycemia Confusion Irritability Headaches Abnormal behavior Weakness Diplopia Inappropriate affect Motor Incoordination Convulsions Coma Exogenous administration of
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