ia_gov_sa · guide · processed · 98 chunks
MOH Pocket Manual in
Emergency
contents
[Non-Text]
الطبيه
السلاميه
Ministry of Health
MOH Pocket Manual in Emergency
Contents
Chapter 1: Cardiac emergency:
• Acute ST Elevation Myocardial Infarction1 .
- Non ST Elevation Myocardial Infarction. Atrial fibrillation.
- Bradydysrhythmias.
- Hypertension.
• Acute Aortic Syndromes.
- Deep Venous Thrombosis.
Chapter 2: Pulmonary emergency:
• Acute bronchial Asthma.
Chapter 3 : Neurological emergency:
- Headache.
• Adult Acute Bacterial Meningitis.
Chapter 4 : Toxicology:
• Acetaminophen (Paracetamol, APAP) Overdose.
• Carbon Monoxide Poisoning.
Chapter 5 : Hematological emergency:
- Sickle cell disease in emergency department.
• Anticoagulation Emergencies.
Chapter 6 : Endocrinology and electrolyte emergency:
- Hypokalemic and Hyperkalemia Emergencies.
• Diabetic emergency.
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• Thyroid Storm and Myxedema Coma
Chapter 7 : Urological emergency:
- Rhabdomyolysis.
• Acute Urinary Retention.
Chapter 8 : Trauma and environmental:
- Severe Traumatic Brain Injury.
• Electrical Injuries.
- Heat injury.
Chapter 9 : Medications List
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Chapter
1
CRADIAC
EMERGENCY
السلام عليك
السلام عليك
Ministry of Health
MOH Pocket Manual in Emergency
Acute ST Elevation and Non
ST Elevation Myocardial Infarction
Overview
Acute coronary syndrome involves:
1. ST elevation acute myocardial infarction
2. Non-ST-segment elevation acute myocardial infarction
3. Unstable angina (UA).
Acute ST elevation myocardial infarction typically occurs when a clot leads to complete occlusion of a coronary artery with trans mural, or full thickness myocardial infarction.
The ECG will show ST segment elevation in the involved area of the heart.
Non–ST-segment elevation acute coronary syndromes (NSTE-ACS) refers to a disease process characterized by reduced coronary blood flow resulting in coronary ischemia without ST-segment elevations on an electrocardiogram (ECG).
NSTE-ACS include both non–ST-segment elevation acute myocardial infarction (MI), as defined by positive biomarkers for MI, and unstable angina (UA), as defined by negative biomarkers.
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الجراح المدنيه
Ministry of Health
Clinical Presentation
○ History
- Chest pain, when it started, what it feels like (stabbing, crushing, pressure, aching), and if it radiates to other parts of the body.
- Jaw/shoulder/ neck/arm pain.
• Dizziness, nausea.
- Shortness of breath.
○ Physical Examination
- Hemodynamic stability, signs of heart failure/left ventricular dysfunction.
- Exclusion of noncardiac and nonischemic cardiac causes requires a thorough examination of the patient's chest wall—including inspection and palpation—as well as careful examination of cardiac and pulmonary functions.
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الطبيه
الخدمه
Ministry of Health
MOH Pocket Manual in Emergency
Differential diagnosis
○ Heart
Acute coronary syndrome
Pericarditis
Myocarditis
Endocarditis
Valvular disease
○ Lungs
Pulmonary embolus
Pneumothorax
Pneumonia
Empyema
Hemothorax
COPD
○ Esophagus
Esophagitis
GERD
Spasm
Foreign body
Rupture (Boerhaave's)
Esophegeal Tear
○ Work up
- CBC.
- Electrolytes.
- Coagulation studies.
- Cardiac enzymes.
- ECG.
- Cardiac biomarkers.
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Management
○ Prehospital Care:
- Three goals:
(1) Delivering patients to an appropriate health care facility as quickly as possible.
(2) Preventing sudden death and controlling arrhythmias by using acute cardiac life support (ACLS) protocol when necessary.
(3) Initiating or continuing management of patients during interfacility transport.
- Checklist to get from the EMS team includes the following information:
1. The person who initiated EMS involvement (patient, family, bystander, transferring hospital) and why.
2. Complaints at the scene.
3. Initial vital signs and physical examination results, as well as notable changes.
4. Therapies given prior to arrival and the patient's response.
5. ECGs done at an outside hospital or en route, noting the context in which notable ECGs were printed.
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السلاميه
MOH Pocket Manual in Emergency
6. The patient's code status (if known).
7. Family contacts for supplemental information and family members who may be on their way to the ED, as they may be helpful in completing or verifying the history.
In hospital care for STEMI:
• Assess and stabilize airway, breathing, and circulation.
- Do ECG.
- Provide oxygen; attach cardiac and oxygen saturation monitors; establish IV access.
- Treat arrhythmia rapidly according to ACLS protocols.
- Give aspirin 162 to 325 mg (non-enteric coated), to be chewed and swallowed (allergy to aspirin is an absolute contraindication).
- Give three sublingual nitroglycerin tablets (0.4 mg) one at a time, spaced five minutes apart if patient has persistent chest discomfort, hypertension, or signs of heart failure and there is no sign of hemodynamic compromise and no use of phosphodiesterase inhibitors, inferior MI with right ventricular extension.
- Give morphine sulfate (2 to 4 mg slow IV push every 5 to 15 minutes) for persistent discomfort or anxiety.
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الجراح الصحي
Ministry of Health
Select reperfusion strategy:
- Primary percutaneous coronary intervention (PCI) strongly preferred, especially for patients with cardiogenic shock, heart failure, late presentation, or contraindications to fibrinolysis.
- Treat with fibrinolysis if PCI unavailable within 90-120 minutes, symptoms <12 hours, and no contraindications
- Give antiplatelet therapy (in addition to aspirin) to all patients:
Patients treated with fibrinolytic therapy: Give clopidogrel loading dose 300 mg if age less than 75 years; if age 75 years or older, give loading dose of 75 mg.
- Give anticoagulant therapy to all patients:
• Unfractionated heparin:
-For patients undergoing primary PCI, we suggest an initial intravenous (IV) bolus of 50 to 70 units/kg up to a maximum of 5000 units.
-For patients treated with fibrinolysis, we suggest an IV bolus of 60 to 100 units/kg up to a maximum of 4000 units and for patients treated with medical therapy (no reperfusion) an IV bolus
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Ministry of Health
MOH Pocket Manual in Emergency
of 50 to 70 units/kg up to a maximum of 5000 units.
-Both should be followed by an IV drip of 12 units/kg per hour (goal aPTT time of 1.5 to 2 times control or approximately 50 to 75 seconds).
Disposition
- Admit to ICU
In hospital care for NSTEMI:
○ Management
- High-risk patient:
:"Early "invasive-
1. Discuss with cardiology.
2. Clopidogrel 300 mg or GPIIb/IIIa inhibitor.
3. Prompt PCI.
- Not high-risk patient:
-Early "conservative":
Clopidogrel 300 mg.
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Disposition
- Admit to ICU.
○ Alert
- Sudden onset of severe pain.
• Occurring during exercise.
- Lasting longer than 15 minutes.
- Associated with shortness of breath.
- Nausea/vomiting and sweating.
- Radiation to left arm or jaw.
- In case of inferior myocardial infarction, you must do Right side and Posterior ECGs to rule out Right ventricular or Posterior MI.
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Ministry of Health
MOH Pocket Manual in Emergency
Atrial Fibrillation: Management Strategies
Overview
○ Cardiac causes:
• Mitral valve disease.
• Myocardial disease.
• Conduction system disorders.
• Wolff-Parkinson-White syndrome.
• Pericardial disease.
Conditions associated with AF include:
• Thyrotoxicosis.
• Hypothermia.
- Alcohol use.
- Severe infection.
- Hypoxia.
• Pulmonary emboli.
- Pneumonia.
• Kidney disease.
- Obesity.
• Diabetes mellitus.
• Digoxin toxicity.
• Electrolyte abnormalities.
- Intrathoracic surgery, such as cardiac or pulmonary surgery, or invasive cardiac studies.
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dajal alsa
Ministry of Health
Atrial Fibrillation is categorized as follows:
• First detected episode.
• Recurrent (after two or more episodes).
• Paroxysmal (if recurrent AF terminates spontaneously).
• Persistent (if sustained beyond 7 days).
Clinical Presentation
○ History
- Anxiety, palpitations, shortness of breath, dizziness, chest pain, or generalized fatigue.
• Medications and alcohol and drug use.
Physical Examination
- Vital signs.
- Oxygen saturation.
- Evidence of thyroid disease (eg, exophthalmos and enlarged thyroid).
- Evidence of deep vein thrombosis/pulmonary embolus (e.g., unilateral lower extremity swelling or tenderness).
- The cardiac evaluation: rate, rhythm, and the presence of heart murmurs.
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Ministry of Health
MOH Pocket Manual in Emergency
Differential diagnosis
<table><tr><td>Rhythm</td><td>Atrial Frequency, beats/min</td><td>Ventricular Frequency, beats/min</td><td>P-wave</td></tr><tr><td>Sinus tachycardia</td><td>100-180</td><td>100-180</td><td>Precedes every QRS complex</td></tr><tr><td>Atrial fibrillation</td><td>400-600</td><td>irregu-,60-190 larly irregular</td><td>Absent</td></tr><tr><td>Atrial flutter</td><td>250-350</td><td>regu-,75-150 lar, sometimes alternating block</td><td>Sawtooth</td></tr><tr><td>Atrioventricular nodal reentrant tachycardia</td><td>180-250</td><td>180-250</td><td>In QRS complex ((R</td></tr><tr><td>Atrial tachycardia</td><td>120-250</td><td>75-250</td><td>Precedes QRS; P-wave differs from sinus P-wave</td></tr><tr><td>Multifocal atrial tachycardia</td><td>100<</td><td>100<</td><td>or more dif- 3 ferent P-wave morphologies at different rates</td></tr></table>
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الجراحه الصحيه
Ministry of Health
<table><tr><td>Atrial fibrillation with Wolff-Parkinson-White syndrome</td><td>400-600</td><td>with ,180-300 wide, bizarre QRS complexes</td><td>Absent</td></tr></table>
Work up
• Electrocardiogram.
• Complete blood cell count.
• Metabolic panel.
• Hepatic function panel.
• Coagulation studies.
• A thyroid panel.
- Chest radiography.
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Ministry of Health
MOH Pocket Manual in Emergency
Management
○ Prehospital Care:
- Cardioversion considered if the patient exhibits signs of hemodynamic compromise or poor coronary artery perfusion.
○ In hospital care:
◆ Unstable Patients: as :
- Altered mental status.
- Ischemic chest discomfort.
- Acute heart failure.
- Hypotension.
- Signs of shock or hemodynamic compromise.
○ Immediate direct current cardioversion:
• 200 J biphasic.
• 200-360 J monophasic.
- Can consider lower energy for atrial flutter.
- Anticipate failure.
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الجراحه الصحيه
Ministry of Health
- If no success repeats direct current cardioversion:
- Increase energy level.
- Consider anterior-posterior pad placement for biphasic defibrillators.
- Time with patient's respiratory cycle, shock during full expiration.
◆ Stable Patients:
If Suspicion for accessory pathway?
• Wide, bizarre QRS complexes.
• Ventricular rate > 250 bpm.
• History of Wolff-Parkinson-White syndrome.
• Prior ECG with delta wave.
○ Give: Amiodarone.
If No suspicious of accessory pathway:
- Diltiazem < 0.2 mg/kg slow IV bolus or 2.5 mg/min drip up to 50 mg total.
Or
- Amiodarone: 150 mg over the FIRST 10 minutes (15
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MOH Pocket Manual in Emergency
mg/min) followed by 360 mg over the NEXT 6 hours (1 mg/min) then 540 mg over the REMAINING 18 hours (0.5 mg/min).
- Beta blockers as :
Esmolol 0.5 mg/kg over one min loading dose then 0.06-0.2 mg / kg/ min
Metoprolol 2.5 -5 mg bolus over 2 min, up to 3 doses.
○ Disposition
- Admission of new-onset AF only for patients with decompensated heart failure or myocardial ischemia or for patients who are highly symptomatic and in whom adequate rate control cannot be achieved.
- Follow your hospital policy of admission.
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الجراح المدنيه
Ministry of Health
○ Alert
- Palpitations during exertion or palpitations with associated syncope or pre-syncope.
- ECG abnormalities.
- Family history of sudden cardiac death or with a first-degree relative affected by an inheritable heart condition.
- Cardioversion needs procedural sedation and analgesia.
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Ministry of Health
MOH Pocket Manual in Emergency
Bradydysrhythmias
Overview
Categories of Bradydysrhythmias
<table><tr><td>Bradydysrhythmia Category</td><td>Bradydysrhythmia Type</td></tr><tr><td>Sinus node dysfunction</td><td>Sinus bradycardiaSinus arrestTachy-brady syndromeChronotropic incompetence</td></tr><tr><td>AV blocks</td><td>First-degree AV blockSecond-degree AV block (Mob-itz type I or Becke)Second-degree AV block (Mob-itz type II)Third-degree AV block (complete heart block)</td></tr></table>
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الجراحه
الطبيه
Ministry of Health
Clinical Presentation
History
Assessing the History of the Patient with Bradydysrhythmia
<table><tr><td>History</td><td>Possible Underlying Pathology</td></tr><tr><td>Preceding angina symptoms</td><td>Myocardial ischemia/infarction</td></tr><tr><td>Fevers, travel to endemic areas, tick bite</td><td>Infectious agent</td></tr><tr><td>Cold intolerance, weight gain, increased fatigue</td><td>Hypothyroidism</td></tr><tr><td>Headache, mental status change, recent head trauma, falls</td><td>Intracranial causes, including intracranial hemorrhage</td></tr><tr><td>Abdominal pain or distention</td><td>Intra-abdominal hemorrhage</td></tr><tr><td>Recent additions or changes to medications</td><td>Drug toxicity</td></tr><tr><td>History of end-stage renal disease, receiving dialysis</td><td>Hyperkalemia</td></tr></table>
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Ministry of Health
MOH Pocket Manual in Emergency
<table><tr><td>Cancer history, receiving treatment</td><td>Acute or long-term toxicity from chemotherapeutic agents</td></tr><tr><td>Severe pain, anxiety, strong emotion preceding the event</td><td>Vasovagal reflex, neurocardiogenic</td></tr></table>
Physical Examination
- Perfusion can be confirmed with the identification of strong peripheral pulses, brisk capillary refill, and warm extremities.
- Evidence of heart failure may be suggested by lower-extremity edema, elevated jugular venous distention, or rales in the lower lung fields.
○ Differential diagnosis
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ajl alhag Ministry of Health
<table><tr><td>Category</td><td>Disease Process</td></tr><tr><td>Ischemia and infarction</td><td>Inferior myocardial infarction, especially involving the right coronary artery</td></tr><tr><td>Neurocardiogenic or reflex-mediated</td><td>Vasovagal reflexHypersensitive carotid sinus syndromeIntra-abdominal hemorrhageIncreased intracranial pressure</td></tr><tr><td>Metabolic, endocrine, and environmental</td><td>HypothyroidismHyperkalemiaHypothermia</td></tr><tr><td>Infectious and postinfectious</td><td>Chagas disease (Trypanosoma cruzi)Lyme disease (Borrelia species)Viral agents (parvovirus B19, coxsackievirus B, etc)Syphilis (Treponema pallidum)</td></tr><tr><td>Toxicologic</td><td>Therapeutic doses of prescribed drugs, overdoses of drugs, or poisoning</td></tr></table>
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dall aljig Ministry of Health
MOH Pocket Manual in Emergency
Work up
• Electrolyte levels, especially potassium.
- A drug level should be obtained on all patients who are currently taking digoxin.
• Thyroid function testing.
• Cardiac biomarkers.
• CT of the head.
- Chest x-ray.
Management
○ Prehospital Care:
- Maintain patent airway; assist breathing as necessary.
- Oxygen (if hypoxemic).
• Cardiac monitor to identify rhythm.
• Monitor blood pressure and oximetry.
- IV access.
• 12-lead ECG, if available.
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ajg
Ministry of Health
- Looking for evidence of hemodynamic instability, including hypotension and altered mentation.
- Treated in the field and en route to the ED by protocols and procedures based on the Advanced Cardiac Life Support (ACLS) algorithm.
In hospital:
○ The Unstable Patient:
- Airway control, oxygen administration, and ventilatory assistance.
- Atropine administration remains the first-line medication for unstable and symptomatic patients with bradycardia.
-The recommended dose is 0.5 mg intravenously every 3 to 5 minutes, with a maximum dose of 3 mg.
- If atropine administration has been ineffective, a beta-adrenergic agent (such as dopamine, epinephrine, or isoproterenol) should be considered.
- Dopamine infusion should be initiated at 2 to \(10\mathrm{mcg / kg / min}\) in patients who have failed to improve with atropine.
Or
- Epinephrine I V infusion 2 to 10 mcg/min.
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dau aljig Ministry of Health
MOH Pocket Manual in Emergency
- Pacing should be initiated in unstable patients who have not responded to atropine or beta-adrenergic agents.
The Stable Patient:
- Identify the underlying etiology of the bradydysrhythmia.
<table><tr><td>Drug or Toxin</td><td>Specific Antidotes and Therapies for Toxicological Causes of BradydysrhythmiasAntidote or Therapy</td></tr><tr><td>Beta blockers</td><td>Glucagon: 5 mg IV; can be repeated every 10 min, up to 3 doses</td></tr><tr><td>Calcium channel blockers</td><td>Calcium gluconate 10%, 30 to 60 cc IV -Insulin (regular): 1 unit/kg bolus + 0.5 - units/kg/h infusion; supplement glucose as needed</td></tr><tr><td>Digitalis (di-goxin</td><td>Digoxin immune Fab (Digibind® or Digi-Fab®): empirically, 10-20 vials (if serum digoxin level is available, product insert can be (used for more exact dosing guide</td></tr><tr><td>Opioids</td><td>Naloxone: 0.4 mg IV, then 2 mg IV if no response</td></tr><tr><td rowspan="2">Organophosphates</td><td>Atropine: 2 mg IV; double every 3-5 min until pulmonary secretions are manageable</td></tr><tr><td>Pralidoxime (2-PAM): 2 g IV over 10-15 min, repeated every 6 h</td></tr></table>
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Disposition
- Symptomatic bradydysrhythmias are admitted.
- Unstable patient admitted to ICU.
Hypertension
Overview
Definitions of Hypertension
Hypertensive emergency
Blood pressure > 140/90 mm Hg with impending or progressive
Target organ dysfunction
Hypertensive urgency
Blood pressure > 180/120 mm Hg without impending or progressive
Target organ dysfunction
Hypertensive crisis
A hypertensive emergency or urgency
Mean arterial pressure
Average blood pressure reading over 1 cardiac cycle; can be
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السلام عليك
السلام عليك
Ministry of Health
MOH Pocket Manual in Emergency
calculated
As [systolic blood pressure + (2 x diastolic blood pressure)] ÷ 3
Essential hypertension
Hypertension without a specific secondary cause
Secondary hypertension
Hypertension related to an underlying pathologic process, e.g., adrenal disease; renal disease; or drug effects, interactions, or withdrawal.
Clinical Presentation
History
Key Questions Regarding History of the Present Illness
Question Comments/Concerns
- Have you ever been told you have high blood pressure?
Open-ended, inclusive question; many people do not think they have high blood pressure if they are taking—or have in the past taken—medication for it.
- Do you have any chest pain?
Myocardial infarction, aortic dissection
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الجراح الصحه
Ministry of Health
- Do you have any shortness of breath?
Myocardial infarction, aortic dissection, pulmonary edema, heart failure
- Are you on any medications, or are you using any recreational drugs or herbal medicines? Neuroleptic malignant syndrome; serotonin syndrome; cocaine, phencyclidine, or other sympathomimetic.
- Have you recently stopped taking any medications or recreational drugs or herbal medicines?
Delirium tremens, clonidine and other drug withdrawal
- Have you had any focal weakness, slurring of speech, numbness, or clumsiness?
Stroke, transient ischemic attack, intracranial hemorrhage
- Do you snore or wake up during sleep? Do you feel tired throughout the day? Obstructive sleep apnea
- Have you had high blood pressure in the past that has not responded to multiple medications?
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MOH Pocket Manual in Emergency
Physical Examination
- Vital signs should be checked and rechecked, including pulses and BPs in all extremities.
• A funduscopic examination.
- Checking the thyroid and reflexes.
- A complete cardiopulmonary examination is critical for establishing the patient's baseline, and an abdominal examination should assess for evidence of an aortic aneurysm.
• The neurologic examination.
Differential Diagnosis
- Stroke.
• Aortic dissection.
- Drug intoxication: cocaine, amphetamine, monoamine oxidase inhibitor.
- Drug withdrawal: antihypertensive, alcohol, sedative hypnotics.
- Renal failure.
• Pheochromocytoma or other.
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- Tumor.
- Thyroid storm.
Work up
• Complete blood cell count.
- Serum chemistry.
• Electrocardiogram.
- Chest radiograph.
- Urine drug screen.
- Urinalysis.
- Pregnancy test.
○ Management
○ Prehospital Care
- Evaluated for signs or symptoms of end-organ damage.
• History, including the medications.
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السلام عليك
السلام عليك
Ministry of Health
MOH Pocket Manual in Emergency
In hospital care:
Asymptomatic Patients with BP Less Than 180/110 mm Hg:
-Patients with BP measurements less than 180/110 mm Hg with no signs of End organ damage, do not need to be treated in the ED
-Instead, these patients should follow up with a primary care provider within 1 week.
Patients with BP Over 180/110 mm Hg and a History Of
Hypertension on Antihypertensive Medications:
-If these patients have missed their medications, they may be restarted on the drugs.
-Efforts should be made to ensure that the barriers that prevented the patient from taking the medications are addressed.
-For those patients who are compliant with their medications but still have an elevated BP, adjustments must be made.
Asymptomatic Patients with BP Over 180/110 mm Hg and No History of Hypertension:
-In this scenario, patients should be started on antihypertensive medication (no need to aggressive lowering of BP), and regular follow-up in OPD clinic.
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الجراحه
الطبيه
Ministry of Health
Parenteral Drugs for Treatment of Hypertensive Emergencies:
<table><tr><td>Drug</td><td>Dose</td><td>Onset of Action</td><td>Dura-tion of Action</td><td>Adverse Effects</td><td>Special Indi-cations</td></tr><tr><td colspan="6">Vasodilators</td></tr><tr><td>Sodium nitro-prusside</td><td>0.25-10 μg/kg/min as IV infusion</td><td>Immedi-ate</td><td>1-2 min</td><td>Nausea, vomiting, muscle twitching, sweating, thiocyanate and cyanide intoxication. May increase intracranial pressure</td><td>Most hyper-tensive emer-gen-cies; caution with high intra-cranial pressure or azote-mia</td></tr></table>
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الطرف
احمد الجيز
Ministry of Health
MOH Pocket Manual in Emergency
<table><tr><td>Nicar-dipine hydro-chloride( not in the MOH formu-lary )</td><td>5-15 mg/h IVinfu-</td><td>5-10 min</td><td>15-30 min, mayexceed 4 hrs</td><td>Tachy-cardia, headache, flushing, local phle-bitis</td><td>Most hyper-ten-sive emer-gen-ciesexcept acute heart fail-ure;caution with coro-naryisch-emia</td></tr><tr><td></td><td>0.1-0.3 μg/kg/min IVinfu-sion</td><td>< 5 min</td><td>30 min</td><td>Tachy-cardia, headache, nausea,flushing</td><td>Most hyper-ten-sive emer-gen-cies;caution with glau-coma</td></tr></table>
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الجراحي
Ministry of Health
<table><tr><td>Nitro-glycerin</td><td>5-100 μg/min as IVinfu-sion</td><td>2-5 min</td><td>5-10 min</td><td>Headache, vomiting, methemo-globin-emia,tolerance with prolonged use</td><td>Coro-nary isch-emia</td></tr><tr><td>Enala-prilat( not in the MOH formulary )</td><td>1.25–5 mg every 6 hrs IV</td><td>15-30 min</td><td>6-12 hrs</td><td>Precipi-tous fall in pressure in high-renin states; variable response</td><td>Acute left ven-tricu-lar fail-ure; avoid in acute myo-car-dial in-farc-tion</td></tr></table>
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احمد الجلz
Ministry of Health
MOH Pocket Manual in Emergency
<table><tr><td rowspan="2">Hydral-azine hydro-chloride</td><td>10-20 mg IV</td><td>10-20 min IV</td><td>1-4 hrs IV</td><td rowspan="2">Tachy-cardia, flushing, headache, vomiting, aggravation of angina</td><td rowspan="2">Ec-lamp-sia</td></tr><tr><td>10-40 mg IM</td><td>20–30 min IM</td><td>4-6 hrs IM</td></tr><tr><td colspan="6">Adrenergic Inhibitors</td></tr><tr><td rowspan="3">Labet-alol hydro-chloride</td><td>20-80 mg IV bolus</td><td>5-10 min</td><td>3-6 hrs</td><td>Vomit-ing, scalp tingling, broncho-constric-tion, dizziness, nausea, heart block, orthostatic hypotension</td><td rowspan="3">Most hyper-ten-sive emer-gen-cies except acute heart failure</td></tr><tr><td>every 10 min</td><td></td><td></td><td></td></tr><tr><td>0.5-2.0 mg/min IV</td><td></td><td></td><td></td></tr></table>
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<table><tr><td>Esmolol hydro-chloride</td><td>250–500 μg/kg/min IV bolus, then 50–100 μg/kg/min by infusion; may repeat bolus after 5 min or in-crease infusion to 300 μg/min</td><td>1-2 min</td><td>10-30 min</td><td>Hypo-tension, nausea, asthma, first-de-gree heart block, heart failure</td><td>Aortic dis-section, peri-opera-tive</td></tr><tr><td>Phentol-amine</td><td>5–15 mg IV bolus</td><td>1-2 min</td><td>10-30 min</td><td>Tachy-cardia, flushing, headache</td><td>Cat-echol-amine excess</td></tr></table>
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Outpatient Oral Medications for Hypertension Management:
<table><tr><td>Agent</td><td>Starting Dose</td><td>Maximum Useful Dos-age</td><td>Indication</td><td>Contraindication</td></tr><tr><td>Thiazide diuretics (eg, hydrochlorothiazide)</td><td>12.5 mg daily</td><td>25 mg daily</td><td>Drug of choice for uncomplicated hypertension1; works well with other agents</td><td>Gout, hypo-kalemia, hypercalcemia</td></tr><tr><td>ACE inhibitor (eg, fos-inopril, lisinopril)</td><td>5-10 mg daily</td><td>40 mg daily</td><td>Patients with CHF, diabetes, previous MI with low ejection fraction</td><td>Bilateral renal artery stenosis; hy-povolemia</td></tr></table>
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الجراحات
الطبيه
Ministry of Health
<table><tr><td>Angioten-sin receptor blockers (eg, losartan)</td><td>25-50 mg daily</td><td>100mg daily</td><td>Similar efficacy to ACE inhibitors; used for patients who cannot toler-ate these inhibitors or in addition to them</td><td>Bilateral renal artery stenosis; hy-povolemia</td></tr></table>
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<table><tr><td>β-Blockers (eg, metopro-lol)</td><td>25-50 mg bid</td><td>200 mg bid</td><td>Patients with coro-nary artery disease; longterm manage-ment of CHF; rate control; hyperthyroidism</td><td>Not a good monotherapy for lone hypertension; heart block; bradycardia; sick sinus syndrome; broncho-spasm; acute decompensated CHF exacerbation</td></tr></table>
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السلام الحج
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<table><tr><td>Calcium channel blockers (eg, diltiazem)</td><td>180-240 mg Daily</td><td>360-540 mg daily (formulation dependent)</td><td>Rate control or coronary artery disease in patients who cannot take β-blockers</td><td>Not a good monotherapy for lone hypertension; long-acting agents are safer than short-acting agents; heart block; bradycardia; acute decompensated CHF exacerbation; sick sinus syndrome</td></tr><tr><td>a-2 Agonist (eg, clonidine)</td><td>0.1 mg bid</td><td>0.3 mg tid</td><td>Hypertension resistant to other modalities</td><td>Poor adherence to medical regimen</td></tr></table>
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<table><tr><td>Hydralazine(unknownmechanism ofvasodilation)</td><td>10 mg 4 qid</td><td>100 mg tid</td><td>Hypertension associatedwith pregnancy;hypertension associatedwith CHFin AfricanAmericansresistant to othermodalities</td><td>Coronary artery disease</td></tr></table>
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الجراح الصحي
Ministry of Health
Disposition
- If the BP is greater than 200/120 mm Hg, oral antihypertensive therapy should be started. For BP greater than 180/110, follow-up should occur within 1 week. If prompt follow-up cannot be ensured, then further consideration for BP treatment or titration of existing BP medications should be given.
- For BP greater than 140/90 mm Hg, follow-up within one week is recommended.
- Patients with hypertensive emergencies admitted to the intensive care unit after receiving titratable IV antihypertensive agents.
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Acute aortic emergency
Overview
Acute aortic syndrome is defined as three related conditions:
(1) Aortic dissection.
(2) Intramural hematoma.
(3) Penetrating atherosclerotic ulcer.
Aortic dissection is defined as:
- Acute if it occurs within 2 weeks of the onset of symptoms.
- Subacute if it occurs between 2 and 6 weeks.
- Chronic if it occurs more than 6 weeks from the onset of pain. (Some authors describe aortic dissections > 2 weeks as chronic).
Two main anatomic classification systems for aortic dissections: that are defined based on the involvement of the proximal aorta
(1) The DeBakey classification.
(2) The Stanford classification.
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الجراحه الصحيه
Ministry of Health
In the DeBakey classification, there are 3 types.
- Type I originates in the ascending aorta and extends into the aortic arch and descending aorta.
- Type II is confined only to the ascending aorta.
- Type III originates in the descending thoracic aorta and is further subdivided into
type IIIa, which is limited to the descending thoracic aorta.
type IIIb, which extends below the diaphragm.
The proximal aorta is defined as the aorta proximal to the brachio-cephalic artery; the descending aorta is defined as the aorta distal to the left subclavian artery.
In the Stanford classification system, aortic dissection is defined .according to whether the ascending aorta is involved or not
- Stanford type A dissections involve the ascending aorta (similar to DeBakey type I and II).
- Stanford type B dissections involve the descending aorta (similar to DeBakey type III).
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Clinical Presentation
○ History
• Time of onset.
- Symptoms.
- location of pain especially in the (chest, back, or abdomen),
• Character of pain.
- Radiation of pain.
• Alleviating or aggravating factors.
• Other associated symptoms.
- Past medical history.
• History of long-standing hypertension.
• Previous cardiac surgery.
• Previous aortic pathology.
• Medications.
• Information about allergies to intravenous iodinated contrast.
• Family history.
• Social history.
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الجراحه
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Physical Examination
- Hypertensive (49%), normotensive (35%), hypotensive (8%), or in shock (8%).
- Pulse deficit.
• The pulmonary examination.
- Cardiac examination: new murmurs, distant heart sounds, jugular venous distension, and tachycardia.
• Neurological findings.
• Mesenteric ischemia.
- Syncope.
Differential diagnosis
• Aortic Regurgitation.
• Aortic Stenosis.
• Cardiac Tamponade.
• Cardiogenic Shock.
• Cardiomyopathy.
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• Cerebrovascular Accident.
• Gastrointestinal Bleed.
• Hemorrhagic Shock.
• Hypovolemic Shock.
• Hiatal Hernia.
• Hypertensive Urgency.
• Mediastinitis.
• Myocardial Infarction.
• Myocarditis.
- Pancreatitis.
- Pericarditis.
- Pleural Effusion.
- Pneumonia.
• Pulmonary Embolism.
• Thoracic Outlet Syndrome.
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○ Work up
- Ultrasound.
• CT.
- MRI.
• Conventional Aortography/Angiography.
CBC.
• Electrolytes.
• Coagulation studies.
• BLLOD GROUPING & CROSS MATCHING.
• Cardiac enzymes.
- LFT'S.
• Pancreatic enzymes.
- Urinalysis.
- ECG.
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Management
○ Prehospital Care:
- Rapidly transporting them to the appropriate facility.
• Transported via advanced life support.
- Intravenous access.
- Cardiac monitor.
• Supplemental oxygen.
- Intravenous fluids should be given if the patient is hypotensive.
- Close monitoring of vital signs.
In hospital care:
- A target heart rate of \(< 60\) beats/min and a systolic blood pressure between 100 and \(120\mathrm{mmHg}\) are recommended to prevent progression of dissection.
- Intravenous narcotics titrated to pain control.
- Intravenous beta-blockers administered first.
Options include propranolol, metoprolol, labetalol, or esmolol.
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الجراح المدنيه
Ministry of Health
- Esmolol has the advantage of a very short half-life, while labetalol is an alpha- and beta-receptor antagonist and may be more effective in controlling both heart rate and blood pressure as a single agent.
- Patients with contraindications to beta-blockers (eg, severe asthma, chronic obstructive pulmonary disease, acute congestive heart failure, or cocaine toxicity) should be given intravenous calcium-channel blockers such as verapamil or diltiazem.
- In cocaine toxicity, intravenous benzodiazepines should be given to decrease the sympathetic drive.
- To further reduce blood pressure, intravenous vasodilator (not used alone).
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<table><tr><td>Medication</td><td>Dosage</td><td>Comments</td></tr><tr><td colspan="3">Beta blockers (recommended as first-line treatment; target heart rate < 60 beats/min</td></tr><tr><td>EsmololBeta 1-receptor blocker</td><td>Bolus 500 mcg/kg IV, then infusion at 50-200 mcg/kg/min</td><td>Preferable due to short half-life and easy titration; may be preferred inasthma/COPD</td></tr><tr><td>LabetalolAlpha 1-, beta 1-, and beta 2-receptor blocker</td><td>10-20 mg IV push q10min up to 300 mg maximum; infusion 0.5-2.0 mg/min</td><td>May be used as a single agent</td></tr><tr><td>MetoprololBeta 1-receptor blocker</td><td>5 mg IV q5min up to 15 mg maximum</td><td>No IV infusion available</td></tr><tr><td>PropranololBeta 1-, beta 2-receptor blocker</td><td>1 mg IV q5 min up to 0.15 mg/kg maximum</td><td>No IV infusion available</td></tr><tr><td colspan="3">Calcium-channel blockers (target heart rate < 60 beats/min)</td></tr></table>
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<table><tr><td>Diltiazem</td><td>Bolus 0.2-0.25 mg/kg IV, then infusion 5-15 mg/.hr</td><td>Second-line for heart rate control when beta blockers are contraindicated (e.g., cocaine toxicity, COPD, or asthma exacerbation)</td></tr><tr><td>Verapamil</td><td>5-10 mg IV</td><td>NA</td></tr><tr><td colspan="3">Vasodilators (give beta blocker first to prevent reflex tachycardia; target SBP 100-120 mm Hg)</td></tr><tr><td>Nitroglycerin</td><td>Start 10-20 mcg/min infusion.Titrate 5-10 mcg/min q10min to a maximum of 100 mcg/min</td><td>Not a first-line vasodilator</td></tr></table>
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Disposition
- Admission to the intensive care unit.
- Close monitoring.
- Strict blood pressure and heart rate control.
- Type A aortic dissections will usually require transfer to a center with cardiac surgery capabilities.
- Type B aortic dissections may be cared for by either a cardiothoracic surgeon or a vascular surgeon, depending on the institution.
- Coordination of care with the treating surgeon will determine whether or not surgical repair is indicated.
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Deep Venous Thrombosis
Overview
- Venous thrombosis is a condition in which a blood clot (thrombus) forms in a vein. This clot can limit blood flow through the vein, causing swelling and pain.
- Most commonly, venous thrombosis occurs in the “deep veins” in the legs, thighs, or pelvis this is called a deep vein thrombosis, or DVT.
Clinical Presentation
○ History
- When did the pain start? The time line of pain onset is important; pain that has been present for weeks without change is unlikely to be acute DVT. This may lead to suspicion for other conditions, such as ongoing arterial insufficiency.
- Did the pain begin with any event, such as localized trauma or a strain?
- Did the pain come on suddenly, or more slowly?
• Were there any associated occurrences with the onset
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of pain, such as a “pop” that may be associated with a muscle, tendon, or cyst rupture?
- Is there any swelling in the leg and, if so, where?
- Is there any redness, or does the skin feel hot?
- Has this ever happened before?
- Have you been immobilized recently, either due to injury/surgery, or for other reasons, such as a lengthy automobile trip?
• Past Medical History:
◆ Malignancy or a history suggestive of malignancy.
Recent hospitalization, pregnancy (including current pregnancy, recent pregnancy (within 2 months), and recent abortions or miscarriages) and the puerperium, use of hormonal agents, or known acquired or inherited thrombophilia.
◆ Obesity and smoking.
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Physical Examination
- Signs of immobility (e.g., presence of a cast).
• Tenderness and its location.
- Swelling or pain upon squeezing the calf.
- Palpation of a painful area, especially the calf, reveals a thickened, thrombosed vein.
Differential diagnosis
- Cellulitis.
- Baker's Cyst.
• Superficial thrombophlebitis.
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Work up
CBC.
• Electrolytes.
• PT/PTT and INR.
- Venography.
- Duplex ultrasound.
- D-Dimer.
Management
○ Prehospital Care:
• Primarily supportive.
- If the patient is asymptomatic, then no need for intravenous access.
- Start heparin if transportation time is prolonged and patient was moderate to high risk.
In hospital care:
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الجراحات
الطبيه
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- Unfractionated heparin using a loading dose of 80 units/kg, then 18 units/kg/h.
- The heparin dose is subsequently adjusted based on PTT measurement after 6 hours of infusion, usually once the patient has been admitted to the hospital.
- Low molecular weight heparin as:
- Enoxaparin one mg /kg SC every 12 hours.
- Delteparin 100IU/kg SC every 12 hours.
OR
200IU/kg SC every day.
- Tinzaaparin 175 IU/kg SC every day.
Disposition
- Admit most patients with DVT for intravenous unfractionated heparin.
- Patients who are sent home after a negative duplex ultrasound should have a repeat ultrasound examination in 5 to 7 days.
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- Patients who are low-risk, have a negative duplex ultrasound, and a negative (reliable) D-dimer do not require any further ultrasound examination, unless the concern for DVT otherwise increases (e.g., worsening symptoms).
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Chapter
2
PULMONARY
EMERGENCY
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MOH Pocket Manual in Emergency
Acute Bronchial Asthma in the Emergency Department
Overview
- Risk Factors for Death from Asthma:
- Previous severe exacerbation (ie, intubation, ICU admission).
- Two or more hospitalizations for asthma in the past year.
• Three or more ED visits for asthma in the past year.
- Hospitalization or ED visit for asthma in the past month.
- Using > 2 canisters of a short-acting beta agonist per month.
- Difficulty perceiving asthma symptoms or severity of exacerbations.
• Social History.
- Low socioeconomic status or inner-city residence.
- Illicit drug use.
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• Major psychosocial problems.
• Comorbidities.
• Cardiovascular disease.
- Concomitant lung disease.
• Chronic psychiatric disease.
Abbreviations: ED, emergency department; ICU, intensive care unit.
Clinical Presentation
○ History
• Past history of sudden severe exacerbations
• Prior intubation for asthma
• Prior asthma admission to an intensive care unit
- Two or more hospitalizations for asthma in the past year
- Three or more emergency department care visits for asthma in the past year
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- Hospitalization or an emergency department care visit for asthma within the past month
- Use of \(>2\) MDI short-acting \(\beta 2\)-agonist canisters per month
- Current use of or recent withdrawal from systemic corticosteroids
- Difficulty perceiving severity of airflow obstruction
- Comorbidities such as cardiovascular diseases or other systemic problems
- Serious psychiatric disease or psychosocial problems
- Illicit drug use, especially inhaled cocaine and heroin
Physical Examination
- Alterations in mentation or consciousness.
- Diaphoresis.
- Tachypnea and tachycardia
• Use of accessory muscles of respiration.
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- Wheezing.
- Identify the complications of asthma such as pneumonia, pneumothorax, or pneumome-diastinum.
Differential diagnosis
Adults
Chronic obstructive pulmonary disease
Acute coronary syndromes
Congestive heart failure
Pulmonary embolism
Pneumothorax
Pneumonia
Airway foreign body
Gastroesophageal reflux disease
Vocal cord dysfunction
Cystic fibrosis
Chronic bronchitis
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Sinus disease
Upper respiratory tract infection.
Children
Croup
Viral and bacterial pneumonia
Airway foreign body
Bronchiolitis
Tracheomalacia
Viral upper respiratory tract infection
Work up
- Complete blood count (if patient is for admission).
- Electrolyte evaluation (if patient has dehydration or for admission)..
- Arterial blood gas (if patient is not responding to initial treatment).
- Chest radiography (if there is no response to treatment or pneumonia).
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الجراحه
الطبيه
Ministry of Health
Management
○ Prehospital Care:
• Oxygenation monitoring with pulse oximetry,
- Hemodynamic monitoring with noninvasive blood pressure.
- Inhaled short acting beta agonists by nebulizer or metered-dose inhaler with spacer.
In hospital care:
<table><tr><td></td><td>Mild-Moderate</td><td>Severe</td></tr><tr><td>\( FEV_1 \) or \( PEFR\% \)</td><td>>50%</td><td>Unable or <50%</td></tr><tr><td>Oxygen</td><td>Maintain \( SaO_2 \) >90%</td><td>Maintain \( SaO_2 \) >90%</td></tr><tr><td>Nebulized solution</td><td>5 mg q20–30 min × 3 doses</td><td></td></tr><tr><td>Salbutamol (ven-toline)</td><td></td><td></td></tr><tr><td>MDI with spacer: Racemic albuterol (90 mg/puff)</td><td>6–12 puffs q20 min for up to 4 hr. (with supervision)</td><td>Same but may be unable to do (with super-vision)</td></tr></table>
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<table><tr><td>Inhaled anticholinergic: Nebulized ipratropium solution</td><td>0.5 mg q20–30 min × 3 doses (mix with albuterol solution)</td><td></td></tr><tr><td>Systemic cortico-steroids</td><td>Oral (preferred):40–60 mg prednisone or equivalentIV (unable to take PO or absorb):60–125 mg methylprednisolone (or equivalent)</td><td>40–60 mg prednisone or equivalent60–125 mg methylprednisolone (or equivalent)</td></tr><tr><td>IV magnesium sulfate (FEV\( _{1} \) <25%)</td><td>Not indicated</td><td>2–3 g over 20 min</td></tr></table>
FEV1, forced expiratory volume in 1 second; MDI, metered-dose inhaler; PEFR, peak expiratory flow rate; SaO2, oxygen saturation in arterial blood.
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الجراح الصحي
Ministry of Health
Disposition
<table><tr><td></td><td>Good Re-sponse</td><td>Incomplete Response</td><td>Poor Re-sponse</td></tr><tr><td>\( FEV_1 \) or \( PEFR\% \) (predicted/personal best)</td><td>>70%</td><td>>50% but <70%</td><td><50%</td></tr><tr><td colspan="4">Disposition site:</td></tr><tr><td>Home</td><td>Yes</td><td>No, continue therapy</td><td>No, continue therapy</td></tr><tr><td>Observation unit</td><td>No</td><td>Yes, if available</td><td>Yes, if available and appropriate</td></tr><tr><td>Hospital ward</td><td>No</td><td>Yes, if no observation unit.</td><td>Yes, if appropriate</td></tr><tr><td>Critical care unit</td><td>No</td><td>No</td><td>Yes, if with respiratory insufficiency/failure</td></tr></table>
\( FEV_{1} \) , forced expiratory volume in 1 second; PEFR, peak expiratory flow rate.
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Alert
• Still have significant symptoms.
- Concerns about compliance (with treatment regime).
• Living alone or socially isolated.
• Psychological problems.
• Physical disability or learning difficulties.
• Previous near fatal or brittle asthma.
- Exacerbation despite adequate dose steroid tablets pre-presentation (current steroid use).
• Presentation at night.
- Pregnancy.
- Normal \(\mathrm{PCO}_2\) is a worsening sign.
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3
NEUROLOGICAL
EMERGENCY
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Acute Headache
Overview
○ Tension-Type Headache
1. At least 10 episodes of headache attacks lasting from 30 minutes to 7 days
2. At least two of the following criteria:
- Pressing/tightening (nonpulsatile) quality
- Mild or moderate intensity (may inhibit but does not prohibit activity)
- Bilateral location
- No aggravation by walking, stairs, or similar routine physical activity
3. Both of the following:
- No nausea or vomiting (anorexia may occur)
- Photophobia and phonophobia are absent, or one but not both are present.
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الجراحه
Ministry of Health
Migraine without Aura
1. At least five headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated), which have at least 2 of the 4 following characteristics:
- Unilateral location.
- Pulsating quality.
- Moderate or severe intensity (inhibits or prohibits daily activities).
- Aggravated by walking, stairs, or similar routine physical activity.
1. During headache, at least one of the two following symptoms occur:
- Phonophobia and photophobia.
- Nausea and/or vomiting.
Cluster Headache
1. At least 5 attacks of severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 to 180 minutes untreated, with One or more of the following signs occurring on the same side as the pain:
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- Conjunctival injection
- Lacrimation
- Nasal congestion
- Rhinorrhea
- Forehead and facial sweating
- Miosis
- Ptosis
- Eyelid edema
1. Frequency of attacks is from one every other day to 8 per day.
Other Primary Headaches
Includes:
Primary exertional headache
- Hypnic headache.
- Primary thunderclap headache.
- Primary headache associated with sexual activity.
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Clinical Presentation
○ History
• Detailed account of the current headache.
- Special attention to “red flag” symptoms that may suggest a dangerous secondary etiology:
- New headache in-patient older than 50 years of age.
- Maximal intensity within minutes of onset (thunderclap headache).
- Posterior headache with neck pain or stiffness.
- Change in vision.
- Change in consciousness.
- Syncope.
• History of HIV or immunocompromised.
• History of malignancy.
- Pregnancy or postpartum.
• History of neurosurgery or cerebral shunt
- Headache with seizure.
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• The onset.
- Location.
• Quality of the headache as well as associated symptoms.
- Explore differences between the current headache and prior headaches.
- As such, the descriptive “worst headache” must be taken in the context of other signs and symptoms.
Important Secondary Causes of Headache:
<table><tr><td>Secondary Headache Causes</td><td>Red-Flag Findings</td></tr><tr><td>Subarachnoid hemorrhage</td><td>Thunderclap (sudden, severe onset) headache</td></tr><tr><td>Meningitis</td><td>Fever, neck stiffness, immunosuppression</td></tr><tr><td>Temporal arteritis</td><td>Jaw claudication, vision changes, polymyalgia rheumatica</td></tr><tr><td>Carbon monoxide poisoning</td><td>Waxing and waning headache, cluster of cases</td></tr><tr><td>Acute glaucoma</td><td>Unilateral vision change, eye pain, and redness</td></tr></table>
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<table><tr><td>Cervical artery dissection</td><td>Neck pain, trauma, stroke symptoms, Horner syndrome</td></tr><tr><td>Venous sinus thrombosis</td><td>Pregnancy, postpartum, hypercoagulable, oral contraceptive use</td></tr><tr><td>Intracerebral tumor</td><td>Chronic progressive headaches, papilledema, history of malignancy</td></tr><tr><td>Cerebellar infarction</td><td>Ataxia, dysmetria, vertigo, vomiting</td></tr><tr><td>Idiopathic intracranial hypertension</td><td>Papilledema, worse when lying flat, obesity</td></tr><tr><td>Pituitary apoplexy</td><td>Hypotension, hypoglycemia, hyponatremia, visual field deficit, history of pituitary tumor</td></tr><tr><td>Pre-eclampsia</td><td>Hypertension, proteinuria, nondependent edema, pregnancy</td></tr><tr><td>Hypertensive encephalopathy</td><td>Altered mental status, hypertensive, neurologic signs in nonanatomic distribution</td></tr><tr><td>Subdural hematoma</td><td>Trauma, coagulopathy</td></tr><tr><td>Intracerebral hemorrhage</td><td>Hypertension, cerebral aneurysm, arteriovenous malformation</td></tr></table>
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Physical Examination
• Neurologic Examination.
• Ophthalmologic Examination.
• Head and Neck Examination.
- Cardiopulmonary and abdominal examinations.
<table><tr><td colspan="2">General History Questions For Evaluation Of Headache</td></tr><tr><td>History Questions</td><td>Concerning Responses</td></tr><tr><td>Onset:When did the headache start?What were you doing when it started?</td><td>Sudden headache with exercise, coughing, straining, or orgasm is concerning for SAH.</td></tr><tr><td>Provocation:What makes the pain better or worse? Position?Exercise? Straining?</td><td>Pain exacerbated by supine position or cough is concerning for increased ICP.</td></tr><tr><td>Quality:Describe the pain.Where is the pain located?</td><td>Occipital headache with neurologic signs of dysarthria, dysphagia, double vision, or ataxia are concerning for posterior bleed, tumor, or stroke.</td></tr></table>
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الطريقه
Ministry of Health
<table><tr><td>Radiation:Does the pain move or radiate?</td><td>Pain with radiation down the neck or neck stiffness is concerning for SAH, meningitis, or carotid or vertebral artery dissection.</td></tr><tr><td>Severity:How long until your headache reached its maximum?</td><td>Thunderclap headache (maximal pain within minutes of onset) is concerning for secondary pathology including SAH, venous sinus thrombosis, or intracranial hemorrhage.</td></tr><tr><td>Temporal:Has the pain changed over time</td><td>Chronic, progressively worsening headaches are concerning for possible structural mass or lesion.</td></tr><tr><td>Associated:Are there any other symptoms you have had?</td><td>Associated neurologic deficits, vision changes, or fever are concerning for dangerous secondary etiology.</td></tr><tr><td colspan="2">Abbreviations: ICP, intracranial pressure; SAH, subarachnoid hemorrhage</td></tr></table>
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السلام عليك
Ministry of Health
MOH Pocket Manual in Emergency
<table><tr><td colspan="2">Selected Concerning Neurologic Examination Findings For The Headache Patient</td></tr><tr><td>Cranial Nerve/Examination Finding:</td><td>Possible Cause:</td></tr><tr><td>CN II – Optic nerve or its central connections• Vision loss / visual field deficit</td><td>• Unilateral vision loss can be the result of ischemia, temporal arteritis, glaucoma, or optic neuritis.• Bilateral visual field loss suggests CNS involvement posterior to the optic chiasm.</td></tr><tr><td>CN III – Oculomotor nerve• Defect in pupillary constric-tion, eyelid raise, extraocular movements (down and out eye)</td><td>• May indicate posterior com-municating artery aneurysm, uncal herniation, SAH, or mass lesion.• Consider cavernous sinus thrombosis.</td></tr><tr><td>CN VI – Abducens nerve• Defect in lateral movement of eye</td><td>• Consider increased or de-creased ICP, brain herniation.</td></tr></table>
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الجراحه
الضريه الصحي
Ministry of Health
<table><tr><td>Ataxia, coordination deficit• Unsteady gait, unable to perform finger-to-nose, heel-to-shin</td><td>• Consider cerebellar infarct or bleed.• Consider posterior/vertebral injur</td></tr><tr><td>Altered mental status</td><td>Concern for mass or vascular lesion, SAH, hypertensive encephalopathy, meningitis, venous sinus thrombosis, carbon monoxide poisoning, or dissection.</td></tr><tr><td>Abbreviations: CN, cranial nerve; CNS, central nervous system; ICP, intracranial pressure; SAH, subarachnoid hemorrhage.</td><td></td></tr><tr><td></td><td></td></tr></table>
Differential diagnosis
• Trauma, SAH, CNS tumor/mass.
- Cerebral/dual venous thrombo-sis, pituitary apoplexy, hyper-tensive encephalopathy.
- Meningitis, SAH, idiopathic intracranial hypertension.
- Acute glaucoma.
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àùjìg
Ministry of Health
MOH Pocket Manual in Emergency
• Temporal arteritis.
• Carbon monoxide.
○ Work up
• Noncontrast head computed tomography (CT).
• (MRI).
• Magnetic resonance venography (MRV) BRAIN.
- Lumbar puncture with cerebrospinal fluid analysis.
• Visual acuity and intraocular pressure.
- ESR.
- Carboxyhemoglobin.
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الجراحه
الضريه
Ministry of Health
<table><tr><td colspan="2">Excluding Secondary Causes Of Headache, By Study</td></tr><tr><td>Test</td><td>Secondary Cause</td></tr><tr><td>Noncontrast CT head</td><td>Trauma, SAH, CNS tumor/mass</td></tr><tr><td>MRI/MRV brain</td><td>Cerebral/dural venous thrombosis, pituitary apoplexy, hypertensive encephalopathy</td></tr><tr><td>Lumbar puncture with cerebro-spinal fluid analysis and OP (opening pressure)</td><td>Meningitis, SAH, idiopathic intracranial hypertension</td></tr><tr><td>Visual acuity with IOP</td><td>Acute glaucoma</td></tr><tr><td>Erythrocyte sedimentation rate</td><td>Temporal arteritis</td></tr><tr><td>Carboxyhemoglobin</td><td>Carbon monoxide</td></tr><tr><td colspan="2">Abbreviations: CNS, central nervous system; CT, computed tomography; IOP, intraocular pressure; MRI, magnetic resonance imaging; MRV, magnetic resonance venography; OP, .opening pressure; SAH, subarachnoid hemorrhage</td></tr></table>
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السلام عليك
Ministry of Health
MOH Pocket Manual in Emergency
Management
○ Prehospital Care:
Generalized recommendations include the following:
1. Eliciting a basic history.
2. Evaluating mental status.
3. Performing a brief neurologic examination.
NB: If there is any abnormality in the neurologic or mental status examination or if the patient appears unwell, emergent transport should be activated
In the field, the initial approach includes:
- Making the patient comfortable prior to giving medications.
- Adjusting temperature.
- Minimizing unnecessary light or noise.
- Placement into a comfortable position.
- Acetaminophen can be used as a first-line medication.
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ijg
Ministry of Health
In hospital care:
• Secondary headaches must be excluded first.
Primary headache:
NSAIDs - first-line therapy for migraine headaches:
For mild pain:
- Ibuprofen 400-600 mg PO.
• CONSIDER Sumatriptan 100 mg PO or 6 mg SQ.
For severe pain:
• Diphenhydramine 25 mg IV
- And
• Prochlorperazine 10 mg IV.
Or
• Metoclopramide 20 mg IV.
Consider
• Dexamethasone 10 mg IV.
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الطبيه
Ministry of Health
MOH Pocket Manual in Emergency
- IV Fluid.
- Triptan.
- Consider expert consultation.
Contraindications for Triptan Use:
• Uncontrolled hypertension.
• Ischemic heart disease.
- Prinzmetal angina.
• Cardiac arrhythmias.
- Multiple risk factors for atherosclerotic vascular disease.
• Primary vasculopathies.
- Basilar and hemiplegic migraine.
• Use of ergot in past 24 hours.
• Use of MAOI or SSRI.
• Use of triptan in past 24 hours.
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الجراحه الصحيه
Ministry of Health
Management of Cluster Headache
Acute abortive therapy for cluster headaches falls into two groups:
1. Oxygen; 6-10 L facemask.
2. And Sumatriptan 6 mg SQ.
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al aljig
Ministry of Health
MOH Pocket Manual in Emergency
<table><tr><td colspan="3">Medications For Primary Headache, Dosing, And American .Academy Of Neurology Quality Of Evidence</td></tr><tr><td>Medication</td><td>Dose</td><td>AAN Quality of Evidence</td></tr><tr><td>Ibuprofen</td><td>mg PO 400-600</td><td>A</td></tr><tr><td>Aspirin</td><td>mg PO 1000</td><td>A</td></tr><tr><td>Naproxen</td><td>mg PO 500-825</td><td>B</td></tr><tr><td>Ketorolac</td><td>mg IV 15-30</td><td>B</td></tr><tr><td>Acetaminophen</td><td>mg PO 900-1000</td><td>B</td></tr><tr><td>Aspirin / acetamino-phen / caffeine</td><td>mg / 500 mg / 130 500 mg PO</td><td>A</td></tr><tr><td>Dihydroergotamine IV</td><td>mg IV 0.5-1</td><td>B</td></tr><tr><td>Chlorpromazine</td><td>mg/kg IV 0.1</td><td>B/C</td></tr><tr><td>Metoclopramide</td><td>mg IV 20</td><td>B</td></tr><tr><td>Prochlorperazine</td><td>mg IV 10</td><td>B</td></tr><tr><td>Sumatriptan SQ</td><td>mg SQ 6</td><td>A</td></tr><tr><td>Sumatriptan PO</td><td>mg PO 100</td><td>A</td></tr><tr><td>Opioids</td><td>Varies</td><td>B</td></tr><tr><td>Dexamethasone</td><td>mg PO/IV 6-10</td><td>C</td></tr></table>
Abbreviations: AAN, American Academy of Neurology; IV, intravenous; PO, by mouth; SQ, subcutaneous
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الجراحه
Ministry of Health
Disposition
• To set return precautions.
Patients should be given return precautions for red-flag signs.
Alerts of Dangerous Secondary Headaches:
- New headache in-patient older than 50 years of age.
- Maximal intensity within minutes of onset (thunderclap headache).
- Posterior headache with neck pain or stiffness.
- Change in vision.
- Change in consciousness.
- Syncope.
• History of HIV or immunocompromised.
• History of malignancy.
- Pregnancy or postpartum.
• History of neurosurgery or cerebral shunt
- Headache with seizure.
- Follow-up with a primary doctor.
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السلام عليك
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