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ER38 Emergency Medicine
Medical Emergencies Toronto Notes 2019
anticoagulation: choice of anticoagulation (unfractionated heparin, LMWH, or fondaparinux) and additional antiplatelet therapy (clopidogrel, ticagrelor, or prasugrel) depends on STEMI vs. NSTEMI and reperfusion strategy
early cardiology consult for reperfusion therapy
◆ UA/NSTEMI: early coronary angiography recommended if high TIMI risk score
◆ STEMI: primary percutaneous coronary intervention (within 90 min) preferred; thrombolytics
if unavailable within 120 min of medical contact, symptoms <12 h and no contraindications atorvastatin 80 mg to stabilize plaques β-blockerifnosignsofCHF,hemodynamiccompromise,bradycardia,orseverereactiveairwaydisease ACEI initiated within 24 h
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Sepsis
• seeInfectiousDiseases,ID21andRespirology,R34 • definitions
■ sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection ◆ organ dysfunction defined as a change in baseline SOFA score ≥2 points
■ septic shock: profound circulatory, cellular, and metabolic abnormalities with greater risk of mortality than with sepsis alone
◆ require vasopressors to maintain MAP ≥65 mmHg
◆ associated with serum lactate ≥2 mmol/L without hypovolemia • management
■ early recognition of sepsis and investigations to locate source of infection ■ identify severe sepsis with lactate or evidence of tissue hypoperfusion
■ early “goal-directed” therapy: ensure adequate organ perfusion
■ treatment priorities:
◆ ABCs, monitors, lines
◆ aggressive fluid resuscitation; consider ventilatory and inotropic support
◆ cultures, then early empiric appropriate antibiotics - consider broad spectrum and atypical
coverage
◆ source control - e.g. remove infected Foley or surgery for ischemic gut
◆ monitor adequate resuscitation with vital signs, inferior vena cava on U/S, and serial
measurement of serum lactate
Stroke and Transient Ischemic Attack
• seeNeurology,N48 • definitions
■ stroke: sudden loss of brain function due to ischemia (87%) or hemorrhage (13%) with persistence of symptoms >24 h or neuroimaging evidence
■ TIA: transient episode of neurologic dysfunction from focal ischemia without acute infarction or neuroimaging evidence
• clinicalpresentation
Table 23. Signs and Symptoms of Stroke
7 Causes of Emboli from the Heart
• AFib
• MI
• Endocarditis
• Valvular disease
• Dilated cardiomyopathy • Left heart myxoma
• Prosthetic valves
Differentiation of UMN Disease vs. LMN Disease
General
Signs/ Decreased LOC, Symptoms changed mental
status, confusion, neglect
Language/ Throat
Dysarthria, aphasia, swallowing difficulty
Vision
Diplopia, eye deviation, asymmetric pupils, visual field defect
Coordination
Ataxia, intention tremor,
lack of coordination
Motor
Increased tone, loss of power, spasticity
Sensation Reflex
Loss of sensation
Hyper-reflexia, clonus
• patientswithhemorrhagicstrokecanpresentwithsuddenonsetthunderclapheadachethatisusually described as “worst headache of life”
• strokemimickers:seizure,migraine,hypoglycemia,Todd’sparesis,peripheralnerveinjury,Bell’spalsy, tumour, syncope
Table 24. Stroke Syndromes
Category
Muscular deficit Reflexes
Tone Fasciculations Atrophy Plantar Response
UMN Disease
Muscle groups Increased Increased Absent Absent/ minimal Upgoing
LMN Disease
Individual muscles Decreased/ absent Decreased Present Present Downgoing
Region of Stroke ACA
MCA
PCA VBA
Stroke Syndrome
Contralateral hemianesthesia and hemiparesis (legs > arms/face), gait apraxia, altered mental status, impaired judgement
Contralateral hemianesthesia and hemiparesis (arms/face > legs), contralateral homonymous hemianopsia, ipsilateral gaze
Contralateral homonymous hemianopsia, cortical blindness, impaired memory
Wide variety of cranial nerve, cerebellar, and brainstem deficits: vertigo, nystagmus, diplopia, visual field deficits, dysphagia, dysarthria, facial hypoesthesia, syncope, ataxia
Loss of pain and temperature sensation in ipsilateral face and contralateral body