Emergency Room

[أبـ البراء ـو]

السلام عليكم
نبدأ بإذن الله سلسة حالات الأستقبال وكيفية التعامل معاها
وسأنقل لكم المتبع لدينا فى أستقبال الباطنة بمستشفيات جامعة عين شمس
والأدوية المتاحة
سأكتبها على فترات
الرجاء التركيز ستسفاد كثيرا
هذه خبرة مخالطتى لمدرسين مساعدين ونصائحهم فى الأستقبال
والله الموفق
نبدأ بأكثر الحالات شائعة فى الأستقبال

Haematemsis & melena.

1st aid measures :-

1-Vital data : pulse .. ... Bl.pr.

2-Canula & give : ((haematemsis cocktail )) ...............> Dicynon"hemostatic" , Konakion "vit.k ", Cyclokabron " antifibrinolytic" ,and Zantac
" H2 blocker"

3-Ryle ---------------à Never before canula
*Values : -Ensure no bleeding
-To wash by cold water with or without adrenaline to cause
local VC.

*Continue wash till it become clear to prepare pt. For endoscopy .
N.B.: Pt. Fit for endoscope means :-
- Ryle wash becomes clear .
- Pt. is not shocked.
- Pt is not in encephalopathy.

4- 3 blood samples ((obtained from the canula before giving cocktail ))
- One for CBC -----à baseline Hbe
-----àPlat. ((decrease in HCV +ve pt. ))
- One for ****bolic profile ----àRoutine ..
- One for blood preparation.

5- ECG ....to exclude ISHD.

** If bleeding severe or pt not fit for endoscope or not available
endoscope
** We may use Sangstakin ---àinflate gastric ballon with 250-300 cc saline
** sangstakin should not be left more than 48 hours to prevent necrosis .





** Also in case of severe bleeding we can give :-
-Somatostatin:- [Octeriotide = antigrowth hormone] 25-50 ug\h..."one
ampoule contain 100 ug"
- 400 saline or Ringer أميول واحد على مدى 4 ساعات +
Value : VC.
- Glypressin "One ampoule contain 1mg "
2 أميول الآن ثم 1 واحد أميول كل 6 ساعات

$$. Take care :
It cause coronary VC, so give nitroderm patches if blood
pr. Allows.
Glypressin is # in IHD, old age…..
Blood is given if pt. chocked.
Plasma is given if pt INR >1.5
Plat. Is given if pt plat. >50,000
Till blood --àgive Colloid which last in intravascular space more than crystalloids. E.g. : Dextran,haemgel….
If Colloid not available -----à give crystalloids E.g.: Saline, Ringer.



II- History taking :
History of :- chronic liver dis., Gu or Du, Drug Intake : aspirin, NSAID, anticoagulant.

III-Examination : HSM , ascites , flapping tremors….

IV:-Upper GIT endoscope àshould be done when Pt. becomes fit for it .
Value : 1- Diagnostic for cause of bleeding
2- Therapeutic ( as mentioned before).

TTT of bleeding Oesophageal varices:

I ) 1st aid measures .
II) Injection sclerotherapy.
III) Anticoma…to avoid encephalopathy..
*Enema \4 h.
* protein restriction 20gm\d.
* Lactulose 30 cm\3 times\d àstopped if diarrhea
*Eradicate bact. Flora :
- Flagyl 250 mg (1*3*7)esp with renal impairment
- Neomycin 500 mg (2*4*5) #with renal impairment.
Side effect : ototoxicity so not given >5days

IV)Guard against SBP by Noroxin (Norfloxacin ) 1*2 .
V) Give (Dicynon ,konakion, Cyclocapron, Zantac) à 2 amp\8h.{ Zantac is # with thrombocytopenia.)

.If bleeding persist we give :-
Sandostatin, Glypressin

After bleeding stopped :
1- follow up GI for injection
.( ميعاد المنظار والحقن )
2Drug to decrease portal hypertensionàIndral 10mg à1*4
(If Indral can't be given as in case of DM\BAor PVD or CHF)
Give Effox 40 mg à1*2
3- Vit. K (1*3)
4- Liver support Eg: Legalon 1*3
5- Diuretics àdepend on pt is compensated or not à i.e. pt has
ascites.

TTT OF PU

a)1st aid measures
b)Upper GIT endoscopy for D.D.-à if active bleeding à injection with adrenaline
c) Losec ( Omeprazole) vial + 200 cc Ringer over 2 hours.
d) If anteral gastritis or Duà Tripple therapy to eradicate h.pylori
It includes :- PPI e.g. : Gastrazole 1*2*15 days
- Clarithromycin 2*2*15 days
- Amoxicilin 2*2*15 days.

Discharge Pt. when :-
Melena stopped
Hb = 8 or more.
Avoid spicy food , smoking , NSAID

NB: If pt. with PU with severe haematemsisà consult à Surgery.

Indication of admission of pt:
Haematemsis, melena
Tense ascitis
SBP
Hepatic encephalopathy
Recommended pt

القادم تكمله للدرس لم أرد أكتب الكثير حتى لا يمل أحد المرة القادمة
متابعة للجوانب الأخرى المصاحبة غالبا لل
Haematemsis & melena
EX
Tense ascitis ( TTT)
Tapping
SBP ( spontinous bacterial peritonitis ):
Hepatic encephalopathy


سأضيف على المقالة كل يوم خميس أو جمعة بإذن الله
لأنه يوم أجازتى

 

[الشافعى الصغير]

جزاك الله خيرا
ننتظر المشاركة القادمة
فلا تحرمنا منها

 

[أبـ البراء ـو]

جزانا وأياكم
أخى الشافعى
لو تكرمت كتبت السنة التى أنت بها لازودك بالمزيد بالمعلومات الدراسية أو لو أنهيت الدراسة أو أردت أى معلومات
سأحاول توفيرها لك بإذن الله  

[أبـ البراء ـو]

Tense ascitis ( TTT)

1-Rest in bed.2-Salt restriction ( salt free diet )3-Diuretics:

a) Start with Spironolactone (Aldactone) 100 mg قرص بعد الغداء

And increase gradually up to 4 tablets \day Value : K sparing diuretic, Aldosterone antagonist.

b) Lasix 40 mg daily up to 4 tablets ( 160 mg\d)

N.B.: Diuretics esp. Lasix stopped if there is hyopkalemia or precoma

4-Follow up pt. with fluid chart

(body wtàtarget: decrease B.wt by 1\2 kg \day.)

5-If resistant à Tapping or paracentesis should be done if tense ascitis cause significant discomfort or resp. distress ( Therapeutic purpose of tapping )



6-Tapping:


a-Exclude encephalopathy. b-Palpation of abdomen to avoid injury to any organ during tapping . c-Sterilization of (Macburny's point) or mid way bet. Costal margin & ASIS( most dependant area) ***Sterilization is done in circular manner from in into out by betadine then alcohol. d-introduce canula + IV line.
- Replacement with albumin if tapping > 3L (one bottle contain 10gm)

- Stop if : hypotension , bleeding of tapping ,, disturbed conc. Level.



N.B.:-

• Diagnostic purpose of tapping : if suspicion of malignant ascitis or SBP or new onset ascitis.
• Fluid obtained from tapping : 3 samples for : culture & sensitivity, chemistry, pathological exam.
• Indication of Albumin in CLD Pt.:

- Tapping > 3 L of ascitis fluid. - Infection - Surgery - SBP - Hepatorenal $

SBP ( spontinous bacterial peritonitis ):

Infectious complication of portal HTN related ascitis in absence of cause for peritonitis . most commen org : E-coli….



C\P : Pt with CLD with [ marked deterioration precipitate hepaticencephalopathy],, [ fever, abd.pain , tenderness ] ,, [ silent]



D.D : leucocytosis may be present

Diagnostic paracentesisàcell count [WBC >500\ m3\HPF with out sympt.,,PNL >250 \m3\HPF with symptoms ]



TTT: - Antipyretic.

- Antibioticà3rd generation cephalosporin E.g. : cefotaxime "claforan" 1 gm \ 8 h for 5 days unless there is renal failure ((dose adjustment)) - Anticoma measures ( previousely mentioned ) - Albumin.

Hepatic encephalopathy :-

It's neuropsychiatric complex in pts with acute or chronic LCF or portosystemic shunting(i.e.: disorderd conciousness, abnormal behavior…)

Ask about ppt factors in Ch. Liver disease pts :

-Diuretics

- High dietary prot.

- Haematemsis, melena

- Fever (infection)

- SBP

- Severe vomiting or diarrhea, excess tapping of ascitis.

- Hepatotoxicity ( alcohol ,drugs e.g. : sedative, opiod…)



Management :

1-Vital data ((fever. Haematemsis ))2-Canula à sample for ****bolic profile. ( Na, K, Creat, RBS)3-Ryle &wash to exclude haematemsis.4-Chest x ray à ( chest infection. . Rt sided P.effustion.5-ECG





TTT:

1- To avoid prot. In diet. 2- Eradicate bact. Flora by: - Neomycin 500 mg 2*4*5

– Flagyl 250 mg 1*3*7 - Lactulose 30 ml \8 h. (osmotic purgative ) - Enema \4h

3- Hepamerz"L-Arnithine – L-aspanate (2 amp +200cc glucose 10% \12 h.)

à if creat > 3

4-Aminolesan 500ml\12h (AA infusion

5-TTT of the cause :

E.g. : Haematemsis àDicynon ,konakion, cyclokapron ,zantac…….

Infectionà TTT
SBPà Antipyretic, Antibiotic, Anticoma, Albumin……

أنتهيت بتوفيق من الله
المقالة القادمة تمنا كتير لأنها بتقبلنما كل يوم مش شرط فى الأستقبال
إن شاء الله أكتبها قريب

سبحان الله والحمد لله ولا إله إلا الله
سبحانك اللهم وبحمدك أشهد إلا إله إلا أنت أستغفرك وأتوب إليك

 

[أبـ البراء ـو]

Fever

Management:

1-Cold fomentation
2-Cold saline enema (# in diarrhea)
3-NSAIDs: - Paracetamol (R/ Cetal or PyralBrufen or Novalgen
كنت سامع من الأستقبال والحضور أن البارسيتامول مش بيشتغل إلا عند درجة حرارة 38 ) 4Aspegic: - ?? thrombocytopenia - ?? Reye $ 5- Search for the cause: sore throat, chest infection, ear infection, UTI……………

• if u don’t find a cause for fever & fever is prolonged > 2 wks >>>>>> FUO

Investigations For FUO)
1-CBC
2-ESR
3-Blood culture , urine culture , sputum analysis + ZN stain
4-Collagen markers
5-Malaria & Toxoplasmosis
6-Widal & Brucella
7- X- ray chest

UTI:
C/O: dysuria, frequency, urgency, hematuria………….
Ask for urine analysis: if pus cells > 100 / hpf (N=0 /hpf) >>>> ask for urine culture
ttt: Give the best antibiotics which is sulfa or Quinolones e.g.
-Sutrim tab. 2*2*5
-Chemotrim fort 1*2*5
-Septrin 1*2*5
ORQuinolones if there is hypersensitivity to sulfa or resistance to it
-Tarivid 200mg (ofloxacin) 1*2*5
-Oflicin 200mg (ofloxacin) 1*2*5
·if pylonephritis: IV AB is required (hospital admission)
Tonsillitis or oropharingitis:
TTT:
1- Antibiotics for 1 wk:
the best is
– penicillin e.g. Ampiclox 1*4 - 1st generation cephalosporin’s e.g. Velosef or Duricef - Sulfa e.g. Sutrim
2- Antipyretic
3- mouth wash

Otitis Media:
As above + nasal decongestant e.g. Afrin drops 1*3*7

Bronchitis:
As above +
expectorants & mucolytics e.g. Mucosol syrup 1*3
Mucophylline Bronchophene Bisolvon 1*3 Trisolven

• if pneumonia >>>>> it is indication of admission for IV AB ( penicillin & 3rd generation Cephalosporins)

Gastroentritis:
SI → C/O: Watery diarrhea (no blood, no mucous, no tenesmus)
. >>>> this is viral infection >>>> give antiseptic e.g
. streptomycin 1*3
LI → C/O: Diarrhea + blood + mucous + tenesmus + fever

Renal Colic: (loin pain radiating to the groin)
Give Glucolynamine IV >>>>> # IM (may cause abscess)
Papaverine IM >>>>>>>> # IV (cause hypotension)

* if no response give {Ca+ atropine + Buscopan + Papaverine + Brufen** كباب

*Ask for urine analysis, pelviabd. U/S

سبحان الله والحمد لله ولا إله إلا الله والله أكبر