Anaphylaxis Management: Problems with the Current Paradigm and the need for ...Michael Langan, M.D.
Michael Langan, MD
Geriatrician, MGH Senior Health
September 10, 2012
Epi-Port (cartridge housing, portable, fashionable, easy to use)
Epi-Pod (cartridge, removable, replaceable)
A new drug delivery system for treatment of anaphylactic shock
Twist, Turn, Push (TTP)
From concept to patent to market
1:30P.M.-2:30P.M.
Fox Hill Village Auditorium
Sponsored by the MGH Wellness Center
*************************
Anaphylaxis Management: Problems with the Current Paradigm and the need for ...Michael Langan, M.D.
Michael Langan, MD
Geriatrician, MGH Senior Health
September 10, 2012
Epi-Port (cartridge housing, portable, fashionable, easy to use)
Epi-Pod (cartridge, removable, replaceable)
A new drug delivery system for treatment of anaphylactic shock
Twist, Turn, Push (TTP)
From concept to patent to market
1:30P.M.-2:30P.M.
Fox Hill Village Auditorium
Sponsored by the MGH Wellness Center
*************************
Pharmacology Stimulates alpha and beta receptors.pdfaryan9007
Pharmacology Stimulates alpha and beta receptors (alpha receptors at high doses;
beta- 1 and beta- 2 receptors at moderate doses) within the sympathetic nervous system. Relaxes
smooth muscle of bronchi and iris, and is an antagonist of histamine. Pharmacokinetics
Metabolism Inactivated by enzymatic transformation to metabephrine or normetanephrine; these
are subsequently conjugated and excreted in the urine. Elimination Mostly excreted in urine as
inactive metabolites; remainder is excreted as unchanged drug or is conjugated. Onset 5 to 10
min (subcutaneous), 1 to 5 min (inhalation). Duration 4 to 6?h (subcutaneous), 1 to 4 h (IM), 1
to 3 h (inhalation). Indications and Usage Epinephrine 1:1,000 injection Relief of respiratory
distress due to bronchospasm; to provide rapid relief of hypersensitivity reactions to drugs and
other allergens (eg, anaphylactic reactions to drugs, animal serums, insect stings); to prolong the
action of local and regional anesthetics; restore cardiac rhythm in cardiac arrest due to various
causes; treatment of mucosal congestion of hay fever, rhinitis, and acute sinusitis; relieve
bronchial asthmatic paroxysms; symptomatic relief of serum sickness, urticaria, angioneurotic
edema; for relaxation of uterine musculature and to inhibit uterine contractions; epinephrine
injection can be used as a hemostatic agent; in syncope due to complete heart block or carotid
sinus hypersensitivity; for resuscitation in cardiac arrest following anesthetic accidents; used in
open-angle glaucoma. Epinephrine 1:1,000 (auto-injector) and 1:2,000 (auto-injector), Prefilled
syringe Emergency treatment of allergic reactions (type I) including anaphylaxis to insect stings
(eg, bees, fire ants, hornets, yellow jackets, wasps) and biting insects (eg, mosquitoes), allergen
immunotherapy, foods, drugs, diagnostic testing substances (eg, radiocontrast media), and other
allergens, as well as idiopathic anaphylaxis or exercise-induced anaphylaxis. The auto-injectors
and prefilled syringes are intended for immediate self-administration in patients who are at
increased risk for anaphylaxis, including individuals with a history of anaphylactic reactions.
Auto-injectors and prefilled syringes are for immediate use and are not a substitute for immediate
medical attention. Epinephrine 1:10,000 injection Treatment and prophylaxis of cardiac arrest in
the absence of ventricular fibrillation and attacks of transitory atrioventricular heart block with
syncopal seizures; to stimulate the heart in syncope due to complete heart block or carotid sinus
hypersensitivity; for resuscitation in cardiac arrest following anesthetic accidents; in
cardiopulmonary resuscitation, intracardiac puncture and intramyocardial injection of
epinephrine may be effective when external cardiac compression and attempts to restore the
circulation by electrical defibrillation or use of pacemaker fail; seldom used as a vasopressor
except in the treatment of anaphylactic shock and under .
Pharmacology Stimulates alpha and beta receptors.pdfaryan9007
Pharmacology Stimulates alpha and beta receptors (alpha receptors at high doses;
beta- 1 and beta- 2 receptors at moderate doses) within the sympathetic nervous system. Relaxes
smooth muscle of bronchi and iris, and is an antagonist of histamine. Pharmacokinetics
Metabolism Inactivated by enzymatic transformation to metabephrine or normetanephrine; these
are subsequently conjugated and excreted in the urine. Elimination Mostly excreted in urine as
inactive metabolites; remainder is excreted as unchanged drug or is conjugated. Onset 5 to 10
min (subcutaneous), 1 to 5 min (inhalation). Duration 4 to 6?h (subcutaneous), 1 to 4 h (IM), 1
to 3 h (inhalation). Indications and Usage Epinephrine 1:1,000 injection Relief of respiratory
distress due to bronchospasm; to provide rapid relief of hypersensitivity reactions to drugs and
other allergens (eg, anaphylactic reactions to drugs, animal serums, insect stings); to prolong the
action of local and regional anesthetics; restore cardiac rhythm in cardiac arrest due to various
causes; treatment of mucosal congestion of hay fever, rhinitis, and acute sinusitis; relieve
bronchial asthmatic paroxysms; symptomatic relief of serum sickness, urticaria, angioneurotic
edema; for relaxation of uterine musculature and to inhibit uterine contractions; epinephrine
injection can be used as a hemostatic agent; in syncope due to complete heart block or carotid
sinus hypersensitivity; for resuscitation in cardiac arrest following anesthetic accidents; used in
open-angle glaucoma. Epinephrine 1:1,000 (auto-injector) and 1:2,000 (auto-injector), Prefilled
syringe Emergency treatment of allergic reactions (type I) including anaphylaxis to insect stings
(eg, bees, fire ants, hornets, yellow jackets, wasps) and biting insects (eg, mosquitoes), allergen
immunotherapy, foods, drugs, diagnostic testing substances (eg, radiocontrast media), and other
allergens, as well as idiopathic anaphylaxis or exercise-induced anaphylaxis. The auto-injectors
and prefilled syringes are intended for immediate self-administration in patients who are at
increased risk for anaphylaxis, including individuals with a history of anaphylactic reactions.
Auto-injectors and prefilled syringes are for immediate use and are not a substitute for immediate
medical attention. Epinephrine 1:10,000 injection Treatment and prophylaxis of cardiac arrest in
the absence of ventricular fibrillation and attacks of transitory atrioventricular heart block with
syncopal seizures; to stimulate the heart in syncope due to complete heart block or carotid sinus
hypersensitivity; for resuscitation in cardiac arrest following anesthetic accidents; in
cardiopulmonary resuscitation, intracardiac puncture and intramyocardial injection of
epinephrine may be effective when external cardiac compression and attempts to restore the
circulation by electrical defibrillation or use of pacemaker fail; seldom used as a vasopressor
except in the treatment of anaphylactic shock and under .
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
1. Management of Medical
Emergencies in the Office
Jim Holliman, M.D., F.A.C.E.P.
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences
Clinical Professor of Emergency Medicine
George Washington University
Bethesda, Maryland, U.S.A.
8. Causes of Death from Anaphylaxis
ƒ Upper airway edema : 70 % of deaths
ƒ Circulatory collapse : 20 %
ƒ Both : 10 %
9. Anaphylaxis : Causes
ƒ Antibiotics : most common
ƒ Local anesthetics
ƒ Latex
–Should question all patients about latex
allergy ; If allergic, use plastic or nitrile gloves,
nozzles, etc.
10. Penicillin (Pcn) Allergy
ƒ 1. Applies to pcn and all derivatives
ƒ 2. Overall incidence : 2 %
ƒ 3. Anaphylaxis in 1 to 5 cases / 10,000 courses
of treatment
ƒ 4. Fatal in 1 to 2 cases / 100,000 courses
ƒ 5. ? 400 to 800 deaths / year in U.S.
ƒ 6. 75 % of deaths in patient with no history of
pcn allergy
ƒ 7. Increased risk : multiple short courses, or
topical treatment
11. Penicillin Allergy (cont.)
ƒ 8. No predisposition if family member
allergic
ƒ 9. Parenteral route : reactions more frequent
and severe
ƒ 10. Skin test to prove allergy available (not
usually relevant to non-life-threatening
situation)
ƒ 11. Should always observe in office 30 min.
after dose
12. Cephalosporin Allergy
ƒ Much less likely to cause reactions
than pcn
ƒ Cross reactivity : 2 to 5 % (with pcn)
ƒ Negative pcn skin test does not R/O
allergy to cephalosporin
ƒ Low incidence of GI side effects
13. Erythromycin Allergy
ƒ Allergic reactions uncommon
ƒ Most common "allergy" symptoms
reported is vomiting / GI upset
ƒ Incidence of GI symptoms probably
similar between different forms of
erythromycin (base, stearate, estolate,
ethylsuccinate, etc.)
14. Guidelines for Suspected
Antibiotic Allergy
ƒ If penicillin allergic : use erythromycin
ƒ Usually OK to use cephalosporin if pcn allergic
(but not if anaphylaxis to pcn)
ƒ Tetracycline (doxycycline) may substitute for
erythromycin in adults
ƒ Chloramphenicol only indicated if multiple
antibiotic allergies
ƒ Clindamycin sometimes useful but increased
incidence of pseudomembranous colitis
15. Allergy to Steroids
ƒ Yes, it is real
ƒ Rare however
ƒ Usually sensitive to succinate ester
ƒ If real : use acetate ester form
16. General Treatment of Allergic
Reactions
ƒ 1. Remove offending agent if possible
–Stop drug being administered
–Wipe off area if topical
–Consider PO activated charcoal (if drug
given PO)
17. General Treatment of Allergic
Reactions (cont.)
ƒ 2. If only local reaction (only
localized redness, pruritis, swelling) :
–Often no treatment needed
–Or PO antihistamine
ƒ Benadryl 1/2 mg/Kg
ƒ Atarax or
ƒ Vistaril 25 to 50 mg (adults)
18. General Treatment of Allergic
Reactions (cont.)
ƒ 3. If systemic (diffuse pruritis, hives,
any throat or chest symptoms) :
–Place IV or heplock
–Assess vital signs
ƒ If vital signs OK, treatment : SQ epi, PO or IV
antihistamine, PO or IV steroid, Observe one
hour
ƒ Emergent treatment if VS not OK
19. Emergent Treatment of Systemic
Allergic Reaction
ƒ Start this sequence if VS not OK (increased HR, decreased
BP, or any throat tightness, SOB or wheezing) :
–1. Place patient recumbent / supine & start FMO2
–2. SQ epi 0.3 mg (0.01 mg / Kg) ; rub area ; If hypotensive
: dilute epi (1:10,000) & give 0.1 to 0.2 mg IV slowly (never
more than 0.1 mg IV at a time)
–3. IV diphenhydramine or hydroxyzine 1 mg / Kg (50 mg
in adults)
–4. IV steroids (100 mg hydrocortisone)
20. Emergent Treatment of Systemic
Allergic Reaction (cont.)
ƒ 5. IV fluid bolus (LR or NS 1 liter or 20 cc / Kg)
ƒ 6. Metaproteronol or albuterol aerosol if wheezing
(0.2 to 0.5 cc in 3 cc NS)
ƒ 7. Consider IV ranitidine or cimetidine
ƒ 8. Atropine if bradycardic
Dopamine if hypotensive despite IV fluids
Racemic epi aerosol if throat swelling
Early intubation if airway compromise
ƒ 9. Call EMS unless rapid resolution with O2 / epi
21. Local Anesthetic Allergy
ƒ True allergy uncommon
ƒ True allergy more likely with esters
ƒ Most "allergies" reported by patients
are really due to intravascular
injection / vasodilation
ƒ If allergic to one ester, assume allergic
to all ester forms
22. Amide Local Anesthetic Allergy
ƒ True allergy rare
ƒ May really be allergy to preservative
ƒ Can use cardiac lidocaine (100 mg
ampules) if allergy to preservative
suspected (cardiac lido has no
preservative)
25. "Toxic" Reactions to Local
Anesthetics
ƒ Due to direct effects of the drug
ƒ Not due to allergy
ƒ Usually (but not always) occur in three
phases :
–Excitation phase
–Convulsive phase
–CNS / Cardiovascular depression phase
26. Phases of "Toxic" Reaction to
Local Anesthetic
ƒ Excitation phase
–Confusion
–Restlessness
–Sense of impending doom
–Tinnitus
–Perioral paresthesias
–Metallic taste
–Lightheadedness
27. Phases of "Toxic" Reaction to
Local Anesthetic (cont.)
ƒ Convulsive phase
–Loss of consciousness
–Gran mal tonic-clonic seizure
ƒ CNS / Cardiovascular depression phase
–Drowsiness
–May be in coma
–Respiratory depression / apnea
–Hypotension
–Bradycardia
–Heart block
28. Treatment of Toxic Reaction to
Local Anesthetic
ƒ Stop infiltrating anesthetic if any Stage 1 symptoms
ƒ Start an IV
ƒ Support ventilation as needed
ƒ Valium 2.5 to 5 mg IV (or 0.2 mg / Kg in children) for
seizures
ƒ Infuse normal saline or Lactated Ringers bolus if
hypotensive (1 liter in adults, 20 cc / Kg in children)
ƒ Atropine IV (0.5 mg) if bradycardic (often not
effective however), and other standard ACLS
measures as needed
29. Alternatives if Patient Has Multiple
Local Anesthetic Allergies
ƒ Injectable diphenhydramine (Benadryl) :
use 1 % solution (dilute 5% solution 50
mg vials with 4cc NS, limit dose to 10 cc)
ƒ Injectable chlorpheniramine
ƒ Slow normal saline infiltration (benzyl
alcohol preservative)
30. Skin Testing for Local Anesthetic
Allergy
ƒ Unreliable (same for antibiotics)
ƒ May have negative test and still have
allergy
ƒ May have positive test and tolerate drug
OK
31. Treatment of Systemic Allergic
Reactions
ƒ Should observe patient with systemic
reaction at least 2 hours before release
ƒ Keep patient on 3 to 7 day course of steroids
ƒ Keep patient on 3 to 7 day course of
antihistamines
ƒ Not necessary to taper steroid dose (unless
patient on them repetitively)
ƒ Advise patient of allergy ; consider getting
Medic Alert bracelet
32. Constituents of Emergency
Self-Treatment Kits
EpiPen Auto-Injector
Spring-loaded automatic injector with 0.3 ml (0.3 mg) of
(1:1,000) aqueous epinephrine
EpiPen Jr. Auto-Injector
Spring-loaded automatic injector with 0.3 ml (0.15 mg) of
(1: 2,000) aqueous epinephrine
Ana-Kit
Manually operated syringe with 0.6 ml (0.6 mg) of (1:1000)
aqueous epinephrine ; delivered as 0.3 ml to a locking point,
with the ability to deliver a second identical
dose if necessary
Chlorpheniramine : 2 mg chewable tablets (# 4)
33. Oversedation / Vomiting
ƒ Major causes :
–Anesthetic "sensitivity"
–Anesthetic "overdose"
–Narcotic effect
–Drug (+ ETOH) interactions
ƒ Best treatment : prevention
ƒ Major risks :
–Vomiting leading to aspiration, leading to
airway obstruction, pneumonia,
cardiovascular collapse
34. Treatment of Oversedation
ƒ Discontinue anesthetic agent
ƒ Place patient in head-down position
(or turn head to side)
ƒ Support ventilation : most important
–O2 high flow (10 to 15 L /min) by FM
–BVM support
–Attach O2 saturation monitor
35. Treatment for Emesis /
Oversedation
ƒ Head-down position or turn head to side
ƒ Suction with Yankauer catheter
ƒ EMS referral if :
–Any obvious aspiration
–Any chest symptoms (pain, SOB, cough,
wheeze)
ƒ Do not give steroids for treatment
36. Treatment of Oversedation
(cont.)
ƒ Check VS (patient may have decreased response
due to decreased BP instead of oversedation)
ƒ Consider IV reversal agents
–Naloxone (2 mg) for narcotics
–Flumazenil (0.2 to 1 mg) for benzodiazepines
ƒ Consider checking blood sugar (R/O
hypoglycemia)
ƒ Call EMS if does not resolve quickly or if patient
hypotensive
37. Addisonian (Acute Adrenal) Crisis
ƒ Due to failure of adrenal glands to produce sufficient
corticosteroids ; can present as acute emergency
ƒ Causes
–Most common is sudden cessation of corticosteroids
in a patient on chronic steroid treatment (given for
chronic lung disease, autoimmune disease, etc) ,
exacerbated by any stress (such as dental surgery or
infection)
–Can also occur if patient on chronic maintenance
steroids has stressful procedure or infection and does
not receive steroid dose to "cover" the added stress of
the procedure or infection
38. Acute Adrenal Crisis
ƒ Suspect diagnosis when :
–Sudden hypotension in response to stress
/ procedure
–Hypotension does not improve with usual
initial treatments
39. Acute Adrenal Crisis
ƒ Treatment :
–High flow O2
–Place IV
–Normal saline bolus 1 liter (20 cc / kg in
children)
–IV hydrocortisone 100 mg
–Call EMS
40. Acute Adrenal Crisis
ƒ Prevention :
–Should double the daily corticosteroid dose
(in a patient on chronic steroid treatment)
before and for at least several days after a
stressful procedure or when an active infection
is present (may need medical consult if
infection is present since the steroids of course
may interfere with immune response to the
infection)
41. Acute Dystonic Reactions
ƒ Definition :
–An idiopathic reaction to major
tranquilizers and related drugs such as
phenothiazenes (i.e., Compazine or
Prochlorperazine), haloperidol (Haldol),
metaclopramide (Reglan), etc, consisting of
abnormal muscle contractions
–Can occur after single, first time dose, or
in patients who have had the same
medicine before without problem
42. Features of Acute Dystonic
Reactions
ƒ Any of these may be present :
–Protrusion of tongue
–Contorsion (spasm) of facial muscles
–Opisthotonos (painful extension of neck
and back)
–Oculogyric crisis (eyes rolled back)
– +/- laryngospasm
43. Acute Dystonic Reactions
ƒ Treatment is very simple :
–Stop the offending drug
–Give 25 to 50 mg Benadryl IV (be sure to flush the
dose in) : immediate relief
–Continue Benadryl 25 to 50 mg PO QID X 3 to 5 days
to prevent recurrence
ƒ Sometimes difficult to differentiate from
psychotic reactions ; use Benadryl as "test
dose" for this
ƒ Only need to call EMS if does not resolve with
IV Benadryl
46. Severe Hyperventilation
ƒ Most important is to make sure it is only due to
anxiety ; if not sure or possibly due to drug
reaction or cardiac or pulmonary disease, call
EMS
ƒ Previously recommended rebreathing into a
paperbag has been shown to cause significant
hypoxia and probably should not be done ; can
have patient hold both their hands with fingers
interdigitated in front of face to "pretend" to get
same effect ; this may have some placebo effect
47. Hyperventilation
ƒ Consider use of PO or IM hydroxyzine
(Vistaril or Atarax) 50 mg (or 1 mg / kg
in children) as an anxiolytic or use
Valium 2 to 5 mg PO or Ativan 1 mg IM
or PO
ƒ OK to use oxygen initially ; does not
exacerbate hyperventilation (and is
important to use if cause is other than
anxiety)
48. Hypoglycemia
ƒ Usually IDDM patient
–Decrease PO intake
–Increase activity (exercise)
ƒ Also in NIDDM patient
–Oral hypoglycemic drugs cause longer
duration hypoglycemia than does insulin
excess
49. Hypoglycemia
ƒ Can occur in non-diabetic patient :
–ETOH ingestion
–Toxic salicylate ingestion
–Malnourished states
–Insulin-producing tumors
ƒ Patients on beta blockers susceptible
50. Hypoglycemia : Symptoms
(any of these may be present)
ƒ Anxiety
ƒ Sleepiness
ƒ Lethargy
ƒ Cold, clammy skin
ƒ Weakness
ƒ Dizziness
ƒ Lightheadedness
ƒ Headache
ƒ Any focal neuro sign
ƒ May have seizure or
coma
ƒ Fatigue
ƒ Confusion
ƒ Palpitations
ƒ Tremulousness
ƒ Sweating
ƒ Hunger
ƒ Combativeness
51. Hypoglycemia : Diagnosis
ƒ Confirm with fingerstick glucose
(ChemStrip)
ƒ Additional serum verification by lab not
always required
52. Hypoglycemia : Treatment
ƒ 1. If reasonably alert and able to manage own airway, then give
glucose-containing gel or fluid PO
ƒ 2. Otherwise start IV (draw red top or green top tube of blood if
possible also so that diagnosis can be confirmed later in lab) and
give 1 amp (50 cc) of 50 % dextrose in water (for child give 1 gm /
kg IV of 25 % dextrose in water)
ƒ 3. May need to repeat dose once
ƒ 4. If unable to start IV : consider glucagon 1 mg IM (only works if
glycogen stores OK in liver)
ƒ 5. Call EMS if patient not a known diabetic or if no rapid response
to initial treatment with sugar
ƒ Important to diagnose and treat quickly to prevent hypoglycemic
neuronal damage
53. Hypertension Emergencies
ƒ Hypertensive crisis (emergency) :
–Severe elevation in blood pressure with
rapid or progressive CNS, cardiac, renal, or
hematologic deterioration
ƒ Hypertensive " urgency " :
–Elevated BP but no symptoms of end-
organ damage
–BP reduction over 24 to 48 hrs.
recommended
54. Hypertension : Treat, Refer, or
Ignore ?
ƒ Level of BP requiring acute treatment in the
asymptomatic patient is controversial among M.D.'s
–Usually however does not need STAT Rx
ƒ Be sure to repeat BP in both arms and after patient
has relaxed for 15 minutes before considering referral
ƒ Remember BP will increase in non-hypertensive
patient due to pain, stress, anxiety, etc.
ƒ Probably should document patient advised of
increased BP if checked in office
55. Specific Criteria for Hypertensive Crisis
(Presence of Listed Item and BP)
ƒ Start treatment and transfer to ED to admit
–Encephalopathy (altered mental status)
–Vomiting : protracted
–Seizures
–CVA / intracranial hemorrhage
–Angina / MI / pulmonary edema
–Aortic dissection
–Eclampsia (toxemia)
–? ARF
? grade III / IV retinopathy
? hemolytic anemia / DIC
? epistaxis
56. Conditions That May Mimic
Hypertensive Crises
ƒ Acute left ventricular failure
ƒ Uremia from any cause, particularly with
volume overload
ƒ Cerebral vascular accident
ƒ Subarachnoid hemorrhage
ƒ Brain tumor
ƒ Head injury
ƒ Epilepsy (postictal)
57. Conditions That May Mimic
Hypertensive Crises (cont.)
ƒ Collagen diseases, particularly lupus
erythematosus, with cerebral vasculitis
ƒ Encephalitis
ƒ Acute anxiety with hyperventilation syndrome
ƒ Drug ingestion (phenacetin)
ƒ Acute intermittent porphyria
ƒ Hypercalcemia
ƒ Malignant hyperthyroidism
58. Causes of Hypertensive
Crises
ƒ Accelerated hypertension
–Hypertensive encephalopathy (malignant hypertension)
–Uncontrolled primary hypertension
–Renal vascular disease
–Toxemia of pregnancy
–Pheochromocytoma
–Intake of catecholamine precursors in patients taking
monoamine oxidase inhibitors
–Head injuries
–Severe burns or trauma
–Rebound hypertension after withdrawal of antihypertensive
drugs
59. Causes of Hypertensive Crises
(cont.)
ƒ Severe to moderate hypertension
accompanying :
–Acute left ventricular failure
–Intracranial hemorrhage
–Dissecting aortic aneurysm
–Postoperative bleeding
–Severe epistaxis
60. ƒ Blood pressure
–Diastolic usually greater
than 130 mm Hg
ƒ Funduscopic findings
–Hemorrhages
–Exudates
–Papilledema
ƒ Renal symptoms
–Oliguria
–Azotemia
ƒ Gastrointestinal
symptoms
–Nausea
–Vomiting
Signs and Symptoms of
Hypertensive Crises
62. Specific BP Levels For Emergent
Treatment
ƒ Hypertensive encephalopathy
ƒ Cerebral infarction
ƒ Intracerebral hemorrhage >200/130
ƒ Subarachnoid hemorrhage
ƒ Eclampsia >140/90
ƒ MI / CHF / Aortic dissection >130 to 140 / 90 to
100
63. Treatment of Hypertensive Crisis
in the Office
ƒ High flow O2
ƒ Call EMS
ƒ Consider placing IV / heplock
ƒ Consider IV narcotic or
benzodiazepine
ƒ Consider SL TNG to decrease BP
acutely (0.4 mg)
ƒ Recheck BP frequently till EMS arrives
64. Options for Office Treatment of
Hypertensive Emergency
ƒ Oral / SL Nifedipine 10 to 20 mg
ƒ Clonidine 0.1 mg to 0.2 mg PO
ƒ Labetolol 100 mg PO or 20 to 40 mg IV
ƒ + IV furosemide 20 to 80 mg
ƒ TNG ointment 1/2" to 1"
ƒ MgSO4 2 gms IV if eclamptic
ƒ Morphine 2 to 4 mg IV (if CHF)
65. Use of Esmolol (Breviblock)
ƒ IV cardioselective beta-blocker
ƒ Chemically similar to metroprolol
ƒ Elimination half-life : 9 min
ƒ Duration of action : <30 min
ƒ May try in ? CHF or ? asthma
ƒ Preparation : 5 g dissolved in 500cc D5W
ƒ Loading dose : 500 mcg/kg/min / 1 min
ƒ Maintenance : 50 mcg/kg/min to 300 mcg/kg/min
ƒ + repeat loading dose before each increase in drip rate
at 4 minute intervals
66. Antihypertensive Meds for
Eclampsia
ƒ Drugs of choice : Hydralazine, Labetolol
ƒ Inhibit uterine contractions : Diazoxide, Calcium
antagonists
ƒ Use only if refractory to other agents :
nitroprusside
ƒ Contraindicated : Trimethaphan (meconium
ileus), "Pure" beta blocker agents ( decreased
uterine blood flow), Diuretics (patient already
volume depleted)
ƒ Don't forget magnesium
68. Treatment of Drug Induced
Hypertensive Crisis
ƒ Labetalol : preferred
ƒ Nitroprusside
ƒ Nifedipine / Verapamil
ƒ Phentolamine
ƒ Since duration of HBP often brief, may not
need treatment
ƒ Note : Pure Beta blockers may cause
increased BP (from unopposed alpha effect)
69. Recommended Minimal Emergency
Drugs / Equipment for the Office
ƒ Oxygen masks / nasal prongs
ƒ Reliable O2 tank supply
ƒ Suction catheters : flexible and Yankauer
ƒ IV catheters : 20 g, 18 g (22 g if children treated)
ƒ 500 cc or 1000 cc bags of NS
ƒ IV tubing sets
ƒ Epinephrine 1 : 1000 vials (1 mg per cc)
70. Recommended Minimal Emergency
Drugs / Equipment for the Office (cont.)
ƒ Atropine 1 to 2 mg vials or amps
ƒ 50cc D50W amps (can dilute these 1:1
with sterile water for pediatric use)
ƒ Benadryl 25 or 50 mg amps
ƒ Valium 5 to 10 mg amps or Ativan 1 to
2 mg amps
ƒ Narcan : 0.4 or 2 mg amps
71. Optional Meds for Office
Emergencies
ƒ Vistaril (or Atarax) 25 or 50 mg amps
ƒ Alupent or albuterol solution for
aerosols or MDI's
ƒ Hydrocortisone 100 mg amps
ƒ Glucagon 1 mg amps
72. Office Emergencies
Lecture Summary
ƒ Be prepared and educate the office
staff about management of
emergencies
ƒ Check office emergency equipment
and meds regularly
ƒ Know how to access local EMS for
help