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EMERGENCIES IN GENERAL PRACTICE - Bradford VTS

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EMERGENCIES IN GENERAL PRACTICE - Bradford VTS Powered By Docstoc
					  EMERGENCIES IN
GENERAL PRACTICE

        By Amina Ahmed
                      &
         Simon Robinson
CASE A
Case A - Anaphylaxis

l   Anaphylaxis is a severe, life-threatening, generalised or systemic
    hypersensitivity reaction.
l   It is characterised by rapidly developing life-threatening airway and/or
    breathing and/or circulation problems usually associated with skin and
    mucosal changes.
l   In general, the more rapid the onset of the reaction, the more serious it
    will be.
l   Symptoms can develop within minutes and early, effective treatment
    may be life saving.
l   Anaphylactic reactions may also be associated with additives and
    excipients in medicines. It is wise therefore to check the full formulation
    of preparations which may contain allergenic fats or oils (including those
    for topical application, particularly if they are intended for use in the
    mouth).
Case A - Anaphylaxis

Signs and symptoms may include:
• Urticaria, erythema, rhinitis, conjunctivitis.
• Abdominal pain, vomiting, diarrhoea and a sense of impending
   doom.
• Flushing is common, but pallor may also occur.
• Marked upper airway (laryngeal) oedema and bronchospasm may
   develop, causing stridor, wheezing and/or a hoarse voice.
• Vasodilation causes relative hypovolaemia leading to low blood
   pressure and collapse. This can cause cardiac arrest.
• Respiratory arrest leading to cardiac arrest.
Case A – Anaphylaxis
Management
Case A – Anaphylaxis
Management
CASE B
Cardiac emergencies

l   The signs and symptoms of cardiac emergencies include chest pain,
    shortness of breath, fast and slow heart rates, increased respiratory
    rate, low blood pressure, poor peripheral perfusion (indicated by
    prolonged capillary refill time) and altered mental state.
l   If there is a history of angina the patient will probably carry glyceryl
    trinitrate spray or tablets (or isosorbide dinitrate tablets) and they should
    be allowed to use them.
l   Where symptoms are mild and resolve rapidly with the patient’s own
    medication, hospital admission is not normally necessary.
l   Sudden alterations in the patient’s heart rate (very fast or very slow)
    may lead to a sudden reduction in cardiac output with loss of
    consciousness.
l   Medical assistance should be summoned by dialling 999.
Case B. Myocardial infarction

Symptoms and signs of myocardial infarction
• Progressive onset of severe, crushing pain in the
   centre and across the front of chest. The pain may
   radiate to the shoulders and down the arms (more
   commonly the left), into the neck and jaw or through
   to the back.
l Skin becomes pale and clammy.
l Nausea and vomiting are common.
l Pulse may be weak and blood pressure may fall.
l Shortness of breath.
Case B. Myocardial infarction
l   Call 999 immediately for an ambulance.
l   Allow the patient to rest in the position that feels most comfortable; in
    the presence of breathlessness this is likely to be the sitting position.
    Patients who faint or feel faint should be laid flat; often an intermediate
    position (dictated by the patient) will be most appropriate.
l   Give high flow oxygen (10 litres per minute).
l   Give sublingual GTN spray if this has not already been given.
l   Reassure the patient as far as possible to relieve further anxiety.
l   Give aspirin in a single dose of 300 mg orally, crushed or chewed.
    Ambulance staff should be made aware that aspirin has already been
    given as should the hospital.
l   Many ambulance services in the UK will administer thrombolytic therapy
    before hospital admission.
l   If the patient becomes unresponsive always check for ‘signs of life’
    (breathing and circulation) and start CPR in the absence of signs of life
    or normal breathing (ignore occasional ‘gasps’).
WITHOUT AED
WITH AED
CASE C
Case C. Epileptic seizures

Symptoms and signs
l There may be a brief warning or ‘aura’.
l Sudden loss of consciousness, the patient becomes rigid, falls,
  may give a cry, and becomes cyanosed (tonic phase).
l After a few seconds, there are jerking movements of the limbs;
  the tongue may be bitten (clonic phase).
l There may be frothing from the mouth and urinary incontinence.
l The seizure typically lasts a few minutes; the patient may then
  become floppy but remain unconscious.
l After a variable time the patient regains consciousness but may
  remain confused.
Case C. Epileptic seizures

l   Fitting may be a presenting sign of Hypoglycaemia and
    should be considered in all patients, especially known
    diabetics and children. An early blood glucose
    measurement is essential in all actively fitting patients
    (including known epileptics).
l   Check for the presence of a very slow heart rate (<40
    per minute) which may drop the blood pressure. This is
    usually caused by a vasovagal episode (see Syncope
    section below). The drop in blood pressure may cause
    transient cerebral hypoxia and give rise to a brief fit.
Case C. Epileptic seizures -
Management
l   During a convulsion try to ensure that the patient is not at risk
    from injury but make no attempt to put anything in the mouth or
    between the teeth (in the mistaken belief that this will protect the
    tongue). Do not attempt to insert an oropharyngeal airway or
    other airway adjunct while the patient is actively fitting.
l   Give high flow oxygen (10 litres per minute).
l   Do not attempt to restrain convulsive movements.
l   After convulsive movements have subsided place the patient in
    the recovery position and reassess.
Case C. Epileptic seizures -
Management
l   If the patient remains unresponsive always
    check for ‘signs of life’ (breathing and circulation)
    and start CPR in the absence of signs of life or
    normal breathing (ignore occasional ‘gasps’).
l   Check blood glucose level to exclude
    hypoglycaemia. If blood glucose <3.0 mmol per
    litre or hypoglycaemia is clinically suspected,
    give oral/buccal glucose, or glucagon (see
    Hypoglycaemia section below).
Case C. Epileptic seizures -
Management
l   After the convulsion the patient may be confused (‘post-ictal
    confusion’) and may need reassurance and sympathy.
l   The patient should not be sent home until fully recovered and
    they should be accompanied.
l   It may not always be necessary to seek medical attention or
    transfer to hospital unless the convulsion was atypical,
    prolonged (or repeated), or if injury occurred. The National
    Institute for Clinical Excellence (NICE) guidelines suggest the
    indications for sending to hospital are:
    l Status epilepticus.
    l High risk of recurrence.
    l First episode.
    l Difficulty monitoring the individuals condition.
Case C. Epileptic seizures -
Management
l   Medication should only be given if seizures are prolonged
    (convulsive movements lasting 5 minutes or longer) or recur in
    quick succession. In this situation an ambulance should be
    summoned urgently.
l   With prolonged or recurrent seizures, ambulance personnel will
    often administer IV diazepam which is usually rapidly effective in
    stopping any seizure.
l   An alternative, although less effective treatment, is midazolam
    given via the buccal or intranasal route in a single dose of 10mg
    for adults. For children the dose can be simplified as follows:
    child 1-5 years 5mg, child 5-10 years 7.5mg, above 10 years
    10mg.
l   This might usefully be administered while waiting for ambulance
    treatment, but the decision to do this will depend on individual
    circumstances.
CASE D
CASE D. HYPOGLYCAEMIA

l   Patients with diabetes should eat normally and take their
    usual dose of insulin or oral hypoglycaemic agent before
    any planned dental treatment.
l   If food is omitted after having insulin, the blood glucose
    will fall to a low level (hypoglycaemia). This is usually
    defined as a blood glucose <3.0 mmol per litre, but some
    patients may show symptoms at higher blood sugar
    levels.
l   Patients may recognise the symptoms themselves and
    will usually respond quickly to glucose.
l   Children may not have such obvious features but may
    appear lethargic.
CASE D. HYPOGLYCAEMIA

Symptoms and signs
• Shaking and trembling.
• Sweating.
• Headache.
• Difficulty in concentration / vagueness.
• Slurring of speech.
• Aggression and confusion.
• Fitting.
• Unconsciousness.
CASE D. HYPOGLYCAEMIA

l   The following staged treatment protocol is a suggested
    depending on the status of the patient. If any difficulty is
    experienced or the patient does not respond, the ambulance
    service should be summoned immediately; ambulance personnel
    will also follow this protocol.
l   Confirm the diagnosis by measuring the blood glucose.
l   Early stages - where the patient is co-operative and
    conscious with an intact gag reflex, give oral glucose (sugar
    (sucrose), milk with added sugar, glucose tablets or gel). If
    necessary this may be repeated in 10 –15 minutes.
CASE D. HYPOGLYCAEMIA

l   In more severe cases - where the patient has impaired
    consciousness, is uncooperative or is unable to swallow safely
    buccal glucose gel and / or glucagon should be given.
    l Glucagon should be given via the IM route (1mg in adults
       and children >8years old or >25 kg, 0.5mg if <8 years old
       or <25 kg). Remember it may take 5-10 minutes for
       glucagon to work and it requires the patient to have
       adequate glucose stores. Thus, it may be ineffective in
       anorexic patients, alcoholics or some non-diabetic patients.
    l   Re-check blood glucose after 10 minutes to ensure that it
        has risen to a level of 5.0 mmol per litre or more, in
        conjunction with an improvement in the patient’s mental
        status.
CASE E
CASE E. ASTHMA

l   Patients with asthma (both adults and children) may have an attack
    whilst at the surgery.
l   Most attacks will respond to a few ‘activations’ of the patient’s own short
    -acting beta2-adrenoceptor stimulant inhaler such as salbutamol (100
    micrograms/actuation). Repeat doses may be necessary.
l   If the patient does not respond rapidly, or any features of severe asthma
    are present, an ambulance should be summoned. Patients requiring
    additional doses of bronchodilator should be referred for medical
    assessment after emergency treatment.
l   If the patient is unable to use the inhaler effectively, additional doses
    should be given through a large-volume spacer device.
CASE E. ASTHMA

Symptoms and Signs
Clinical features of acute severe asthma in adults include:
• Inability to complete sentences in one breath.
• Respiratory rate > 25 per minute.
• Tachycardia (heart rate > 110 per minute).

Clinical features of life threatening asthma in adults include:
• Cyanosis or respiratory rate < 8 per minute.
• Bradycardia (heart rate < 50 per minute).
• Exhaustion, confusion, decreased conscious level.
CASE E. ACUTE SEVERE
ASTHMA MANAGEMENT
l   If the reponse is unsatisfactory and a nebuliser is unavailable, 4
    –6 activations from the salbutamol inhaler should be given using
    a large-volume spacer device and repeated every 10 minutes if
    necessary until an ambulance arrives.
l   If the response remains unsatisfactory and a nebuliser is
    available, give salbutamol 2.5mg-5mg via a nebuliser, and oral
    prednisolone, 30mg stat.
l   If the response remains unsatisfactory and the patient develops
    tachycardia, becomes distressed or cyanosed, arrangements
    must be made to transfer the patient urgently to hospital.
CASE E. ACUTE SEVERE
ASTHMA MANAGEMENT
l   If any patient becomes unresponsive always
    check for ‘signs of life’ (breathing and
    circulation) and start CPR in the absence of
    signs of life or normal breathing (ignore
    occasional ‘gasps’).
CASE F
CASE F. EPISTAXIS

l   Epistaxis is so common that almost everyone has
    had a nosebleed on at least several occasions,
    usually as a result of trauma.
l   It has peaks of incidence at age 2-10 and 50-80
    years old.
l   Both sexes are equally affected.
l   It is classified as anterior or posterior, depending
    upon the source of bleeding
    l   Anterior haemorrhage - The source of bleeding is visible
        in about 90% of cases - usually from the nasal septum
    l   Posterior haemorrhage - This emanates from deeper
        structures of the nose, and occurs more commonly in older
        individuals
CASE F. EPISTAXIS
CAUSES
l  Trauma to the nose (commonest cause) - especially nose picking! Insertion of foreign
   bodies and excessive nose blowing may also be seen as trauma. The latter is likely to
   occur with a cold when the nasal mucosa is congested. Sinusitis causes nasal congestion.
l  Disorders of platelet function. Thrombocytopenia and other causes of abnormal platelets
   including splenomegaly and leukaemia. Waldenström's macroglobulinaemia may present
   with nosebleeds. ITP can occur in children and young adults.
l  Drugs - aspirin and anticoagulants.
l  Disorders of platelets are more likely to be a problem than clotting factor deficiency.
l  Abnormalities of blood vessels. In the elderly arteriosclerotic vessels prolong bleeding.
   Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) causes recurrent
   epistaxis from nasal telangiectasiae.
l  Malignancy of the nose may present with bleeding. Juvenile angiofibroma is a highly
   vascular benign tumour that typically presents in adolescent males.
l  Cocaine Use - If the septum looks sloughed or atrophic ask about use of cocaine.3 The
   drug is usually taken by inhalation and it has a very strong vasoconstrictive effect that can
   lead to complete obliteration of the nasal septum.
l  Other conditions - Wegener's granulomatosis and pyogenic granuloma can present as an
   epistaxis.
CASE F. EPISTAXIS
MMANAGEMENT
Iniatial Assessment, First Aid
l Maintain a calm attitude around the patient - but protect yourself
   (gloves, gown and goggles - the 3Gs).
l Resuscitate the patient (if necessary) - remember the ABCD(E)
   of resuscitation.
l Take a quick history
   l Which nostril is bleeding? Is there blood the pharynx?
   l How much blood loss has there been? Are there symptoms of
       hypovolaemia?
   l Is the bleeding recurrent? What measures have been tried
       before?
   l Past medical history (e.g. recent trauma) and current medication
       (especially aspirin or warfarin).
CASE F. EPISTAXIS
MMANAGEMENT
l   Get the patient to sit upright, leaning slightly forward; and to
    squeeze the bottom part of the nose (NOT the bridge of the
    nose) for 10-20 minutes to try and stop the bleeding . Patient
    should breathe through the mouth and spit out any blood/saliva
    into a bowl. An ice pack on the bridge of the nose may help.
l   Monitor pulse and blood pressure.
l   If bleeding has stopped after this time (as it does in most cases)
    proceed to inspect the nose using a nasal speculum and
    consider cautery.
l   If the history is of severe and prolonged bleeding get expert help
    - and watch carefully for signs of hypovolaemia etc..
CASE F. EPISTAXIS
MANAGEMENT
l   Silver nitrate cautery and naseptin cream
l   Anterior bleeds - Packing
l   Posterior bleeds – packing/ balloon catheter
CASE F. EPISTAXIS
MANAGEMENT
l   These are unnecessary in most (mild) cases
    but recurrent or severe cases require at least
    a FBC, coagulation studies and blood typing.
l   Quite marked anaemia can result but a
    haematological malignancy may also be
    revealed.
l   Any suspicion of malignancy of the nose or
    other abnormality should require referral to
    an ENT surgeon.
CASE G
CASE G - CHOKING

Children are susceptible to choking
Symptoms and Signs
• The patient may cough and splutter.
• They may complain of difficulty breathing.
• Breathing may become noisy with wheeze (usually
   aspiration) or stridor(usually upper airway
   obstruction).
• They may develop ‘paradoxical’ chest or abdominal
   movements.
• They may become cyanosed and lose consciousness.
CASE G – CHOKING
MANAGEMENT
l   The treatment of the choking patient involves removing any
    visible foreign bodies from the mouth and pharynx.
l   Encourage the patient to cough if conscious. If they are unable to
    cough but remain conscious then sharp back blows should be
    delivered. These can be followed by abdominal thrusts if the
    foreign body has not been dislodged.
l   If the patient becomes unconscious, CPR should be started. This
    will not only provide circulatory support but the pressure
    generated within the chest by performing chest compressions
    may help to dislodge the foreign body.
CASE G – CHOKING
MANAGEMENT
CASE H
CASE H - TRAUMA
Trauma Assessment

  The initial assessment and management of seriously injured patients is a
  challenging task and requires a rapid and systematic approach. This systematic
  approach can be practised to increase speed and accuracy of the process but
  good clinical judgement is also required. Although described in sequence some
  of the steps will be taken simultaneously.
  The aim of good trauma care is to prevent early trauma mortality. Early trauma
  deaths occur because of failure of oxygenation of vital organs or central nervous
  system injury or both.

  Injuries causing this mortality occur in predictable patterns and recognition of
  these patterns led to the development of Advanced Trauma Life Support (ATLS)
  by the American College of Surgeons. A standardised protocol for trauma
  patient evaluation has been developed. The protocol celebrated its 25th
  anniversary in 2005. Good teaching and application of this protocol is held to be
  an important factor in improving the survival of trauma victims worldwide.
CASE H – TRAUMA
MANAGEMENT
First and most important:



Is it safe to
 approach?
CASE H – TRAUMA
MANAGEMENT
l   Aims of the initial evaluation of trauma patients
    l   Stabilise the patient
    l   Identify life threatening conditions in order of risk and
        initiate supportive treatment
    l   Organise definitive treatments or organise transfer for
        definitive treatments
l   Preparation and coordination of care Assessment
    and management will begin out of hospital at the
    scene of injury and good communication with the
    receiving hospital is important. The preparatory
    measures are outlined below to 'set the scene':
CASE H – TRAUMA
MANAGEMENT
l   The prehospital phase
    l   Preparation of a resuscitation area
    l   Airway equipment (laryngoscopes etc accessible,
        tested)
    l   Intravenous fluids (warming equipment etc)
    l   Immediately available monitoring equipment
    l   Methods of summoning extra medical help
    l   Prompt laboratory and radiology backup
    l   Transfer arrangements with trauma centre.
l   Guidelines on protection when dealing with
    body fluid should be followed throughout this
    and subsequent procedures.
CASE H – TRAUMA
MANAGEMENT
General principles

1. Follow the Airway, Breathing, Circulation, Disability, and Exposure
    approach (ABCDE) to assess and treat the patient.
2. Treat life-threatening problems as they are identified before moving to
    the next part of the assessment.
3. Continually re-assess starting with Airway if there is further deterioration.
4. Assess the effects of any treatment given.
5. Recognise when you need extra help and call for help early. This may
    mean
dialling 999 for an ambulance.
6. Use all of your resources – ask members of public for help. This will
    allow you to do several things at once, e.g., collect emergency drugs
    and equipment, dial 999.
CASE H – TRAUMA
MANAGEMENT
Initial assessment
This comprises:
l Primary survey

l Resuscitation

l Secondary survey

l Definitive treatment or transfer for definitive
  care
CASE H – TRAUMA
MANAGEMENT
l   A= Airway maintenance cervical spine
    protection
l   B= Breathing and ventilation
l   C= Circulation with haemorrhage control
l   D= Disability: Neurological status
l   E= Exposure/ environmental control
CASE H – TRAUMA
MANAGEMENT
As part of the secondary survey
l History:
 l   A=Allergies
 l   M=Medication currently used
 l   P=Past illnesses/Pregnancy
 l   L=Last meal
 l   E=Events/Environment related to injury
CASE H – TRAUMA
MANAGEMENT
A= Airway maintenance cervical spine protection
l Are there signs of airway obstruction, foreign bodies,
  facial, mandibular or laryngeal fractures?
l Establish a clear airway (chin lift or jaw thrust) but
  protect the cervical spine at all times. If the patient
  can talk the airway is likely to be safe but remain
  vigilant and recheck. GCS less than 8 requires
  definitive airway.
CASE H – TRAUMA
MANAGEMENT
B= Breathing and ventilation
Evaluate breathing:
  lungs, chest wall, diaphragm. Chest examination
  with adequate exposure: watch chest movement,
  auscultate, percuss to detect lesions acutely
  impairing ventilation:
  l   Tension pneumothorax
  l   Flail chest
  l   Haemothorax
  l   Pneumothorax.
CASE H – TRAUMA
MANAGEMENT
C= Circulation with haemorrhage control
l Blood loss is the main preventable cause of death after trauma. To
  assess blood loss rapidly observe:
    l   Level of consciousness
    l   Skin colour
    l   Pulse.
l   Bleeding should be assessed and controlled:
    l   Direct manual pressure should be used (not tourniquets except
        for traumatic amputation as these cause distal ischaemia).
    l   Transparent pneumatic splinting devices may control bleeding
        and allow visual monitoring.
    l   Occult bleeding into the abdominal cavity and around long bone
        or pelvic fractures is problematic.
CASE H – TRAUMA
MANAGEMENT
D= Disability: Neurological status
l After A,B and C above rapid neurological
  assessment is made to establish
    l   Level of consciousness, using Glasgow Coma Scale
    l   Pupils: size, symmetry and reaction
    l   Any lateralising signs
    l   Level of any spinal cord injury (limb movements,
        spontaneous respiratory effort)
l   Note: remember oxygenation, ventilation, perfusion,
    drugs, alcohol and hypoglycaemia may all also
    affect level of consciousness.
CASE H – TRAUMA
MANAGEMENT
E= Exposure/ environmental control
l Undress patient, but prevent hypothermia
  Clothes may need to be cut off, but after
  examination attention to prevention of heat
  loss with warming devices, warmed blankets
  etc is important, Intravenous fluids should be
  warmed before infusion.
CASE I
CASE I – GI BLEEDING
l   Upper gastrointestinal bleeding (UGIB) is a significant and
    potentially life-threatening worldwide problem.
l   Despite advances in diagnosis and treatment, mortality and
    morbidity have remained constant.
l   Bleeding from the upper gastrointestinal tract (GIT) is about 4
    times as common as bleeding from the lower GIT.
l   Typically patients present with bleeding from a peptic ulcer and
    about 80% of such ulcers stop bleeding.
l   Increasing age and co-morbidity increase mortality. It is
    important to identify patients with a low probability of re-bleeding
    from patients with a high probability of re-bleeding.
CASE I – GI BLEEDING
Aetiology
A cause is found in 80% of cases. Approximate percentages given.
Note the predominance of peptic ulcer disease
l Peptic ulcer disease 35 to 50%:
l Gastroduodenal erosions 8 to 15%
l Oesophagitis 5 to 15%
l Oesophageal varices 5 to 10%
l 'Mallory-Weiss' tears 15%
l Upper gastrointestinal malignancy 1%
l Vascular malformations 5%
l Rare causes - less than 5%:
   l   Dieulafoy's lesion (a vascular malformation of the proximal stomach)
       Angiodysplasia; Haemobilia (bleeding from the gallbladder or biliary tree);
       Pancreatic pseudocyst and pseudo-aneurysm; Aortoenteric fistula; Bleeding
       diathesis; Ehlers-Danlos syndrome; Pseudoxanthoma elasticum; Gastric
       antral vascular ectasia; and Rendu-Osler-Weber syndrome
CASE I – GI BLEEDING
l   The strong association of Helicobacter pylori (H. pylori) infection with
    duodenal ulcer is worthy of special mention. The organism disrupts the
    mucosal barrier and causes inflammation in the gastric and duodenal
    mucosae. Eradication reduces the risk of both recurrent ulcers and
    recurrent haemorrhage.

l   Non-steroidal anti-inflammatory drugs (NSAIDS) are the second most
    important aetiological factor. They exert an effect on cyclooxygenase-1
    leading to impaired resistance of the mucosa to acid.

l   The size of the bleeding vessel is important in prognosis. Visible
    vessels are usually between 0.3 mm and 1.8 mm. Large bleeding
    vessels cause faster blood loss. Generally larger vessels are found
    deeper in the submucosa and serosa and more specifically high in the
    lesser curve of the stomach and postero-inferiorly in the duodenal bulb.
CASE I – GI BLEEDING
l   Peptic ulcer disease is the most common cause of UGIB. Risk factors
    for peptic ulcer disease are:
    l   Alcohol abuse
    l   Chronic renal failure
    l   Non-steroidal anti-inflammatory use
    l   Age
    l   Low socio-economic class
l   Although duodenal ulcers are more common than gastric ulcers, both
    contribute nearly equally to the incidence of UGIB. After an initial bleed
    the risk factors for re-bleeding, with associated higher mortality, are:
    l   Age over 60
    l   Presence of signs of shock at admission
    l   Coagulopathy
    l   Pulsatile haemorrhage
    l   Cardiovascular disease
CASE I – GI BLEEDING
Assessment
History
l Is there abdominal pain?
l History of other gastrointestinal symptoms should be
   sought. The symptoms in order of frequency are:
   l Haematemesis including coffee-ground emesis: 40 to 50%
   l Melaena: 70 to 80%
   l Haematochezia (red or maroon stool): 15 to 20%
   l Syncope: 14%
   l Presyncope: 43%
   l Dyspepsia:18%
   l Epigastric pain: 41%
   l Diffuse abdominal pain:10%
   l Weight loss: 12%
   l Jaundice 5%
CASE I – GI BLEEDING
l   Alcohol intake.
l   Past history of bleeding (haematemesis or
    melaena) or of anaemia.
l   Drug history is important. Drugs such as
    NSAIDs, aspirin and corticosteroids are an
    important cause of bleeding. Iron and
    bismuth may mimic melaena.
l   Retching may precede bleeding with a
    'Mallory-Weiss' tear.
CASE I – GI BLEEDING
Examination
l The main aim of examination is to assess blood loss
  and look for signs of shock.
l A secondary aim is to look for signs of underlying
  disease and significant co-morbid conditions. For
  example:
  l   Pallor and signs of anaemia should be sought
  l   Pulse and blood pressure
  l   Postural hypotension may be detected and usually
      indicates a blood loss of 20% or more
  l   Other signs of shock: Cool extremities; Chest pain;
      Confusion; and Delirium
CASE I – GI BLEEDING
l   Evidence of dehydration (dry mucosa, sunken eyes,
    skin turgor reduced)
l   Stigmata of liver disease may be present (jaundice,
    gynaecomastia, ascites, spider naevi, flap etc)
l   Signs of a tumour may be present (nodular liver,
    abdominal mass, lymphadenopathy)
l   Subcutaneous emphysema and vomiting suggests
    Boerhaave's syndrome (oesophageal perforation)
l   Urine output should be monitored (oliguria is a sign
    of shock)
CASE I – GI BLEEDING
Differential Diagnosis
l Abdominal aortic aneurysm
l Boerhaave's syndrome
l Cholecystitis
l Coeliac sprue
l Dengue fever
l Disseminated intravascular coagulation
l Zollinger-Ellison syndrome
l Von Willebrand's disease
CASE I – GI BLEEDING
Assessment of bleeding severity and re-bleeding

Bleeding severity can be assessed by:
   l   The extent of blood loss
   l   The degree of shock

However there are other factors which affect risk of death:
   l   Age: deaths under age 40 years are rare. 30% of patients over 90 years old
       with UGIB die as a result of the bleed.
   l   Co-morbidity: complications are more likely with co-morbid disease.
   l   Shock: the presence of signs of shock confers a worse prognosis.
   l   Endoscopic findings: much work has been done on classifying and
       identifying endoscopic findings which correlate with high risk. For example:
       l   'Mallory-Weiss' tears or clean ulcers have a low risk of re-bleeding and death.
       l   Active bleeding in a shocked patient carries an 80% risk of re-bleeding or
           death.
       l   Non-bleeding but visible vessel has a 50% risk of re-bleeding.
CASE I – GI BLEEDING
Risk of Re-bleeding
l   Various methods have been designed to assess the risk of re-
    bleeding. These include Rockall score (see next slide) and
    Baylor score. Use of these remains controversial.
l   Co-morbid conditions have a significant effect on prognosis, as
    embodied in the Rockall assessment. Patients with advanced
    renal or liver disease and disseminated cancer fare worst.

    Note: the Rockall score is a very useful tool but you should
    always use your clinical judgement in each individual case.
CASE I – GI BLEEDING
CASE I – GI BLEEDING
MANAGEMENT
Rockall score - initial assessment or at admission
l Calculate the initial Rockall score:
    l   If 0, then consider patient for discharge or non-admission
        with out-patient follow-up.
    l   Rockall score >0 - i.e. all other patients - should be
        considered for admission and early endoscopy and should
        have a full Rockall score calculation.
l   Patients who have a Rockall score >0 should have
    an early endoscopy which will allow calculation of
    their full Rockall score.
CASE I – GI BLEEDING
MANAGEMENT
Resuscitation is a priority
l It has been demonstrated that early and aggressive
  resuscitation reduces mortality in UGIB.
  l   Maintain airway - remember vomitus can lead to airway
      obstruction.
  l   Provide high flow oxygen - this will aid tissue perfusion.
  l   Correct fluid losses (place 2 wide bore cannulae and also
      send bloods at the same time). Initial fluid resuscitation
      may be with crystalloids or colloids; give intravenous blood
      when 30% of circulating volume is lost. Major haemorrhage
      protocols should be in place.
CASE I – GI BLEEDING
MANAGEMENT
l   Once patient is more stable
    l   Assess the patient, taking history and examining
        the patient as above - a collateral history might be
        needed.
    l   Identify and treat any co-morbid conditions.
    l   Estimate the severity of bleeding
CASE I – GI BLEEDING
MANAGEMENT
Endoscopy
l  Ideally, endoscopy should be performed within 24 hours.
l  Endoscopy can be used both in diagnosis and therapy.
l  Therapy might involve injection of adrenaline or other sclerosants, thermal
   coagulation or application of clips.
l  Meta-analysis of trials has shown that endoscopic haemostatic techniques
   reduce bleeding, reduce the need for surgery and reduce mortality.
l  Endoscopic therapy should be applied to the following:
    l   Actively bleeding lesion
    l   Non-bleeding visible vessels
    l   Ulcers with adherent clot
l   The preference is for dual therapy, e.g. injection of adrenaline with thermal
    coagulation.
l   High dose PPI should be given to those with major peptic ulcer bleeding, i.e.
    active bleeding or non-bleeding visible vessel.
l   All other patients who do not receive endoscopic therapy should
    commence oral PPI post-procedure.
CASE I – GI BLEEDING
MANAGEMENT
Medical management post-endoscopy
l H. pylori eradication:
  l   All patients with bleeding peptic ulcer should be tested for H. pylori, e.g. urea
      breath test and biopsy specimen.
  l   Patients who test positive should receive a 1-week course of eradication
      therapy.
  l   This should be followed by 3 further weeks with ulcer healing treatment.
  l   All therapy can be discontinued after successful healing of peptic ulcers
      provided patients are not taking NSAIDs.
  l    A negative urea breath test should be confirmed on the initial biopsy
      specimen taken prior to diagnosis and before any PPI therapy was given.
  l   Two weeks after successful therapy and stopping of all medication, a repeat
      urea breath test should be performed to confirm successful eradication.
  l   Unsuccessful eradication should be treated with second-line therapy.
CASE I – GI BLEEDING
MANAGEMENT
Other points to note:
l  PPI use is not recommended prior to diagnosis by endoscopy in the latest SIGN
   guidance, however current hospital protocols often include PPI use for
   suspected UGIB before endoscopic confirmation.
l  There is insufficient evidence to use somatostatin or tranexamic acid in UGIB.
l  In selected patients (e.g. variceal haemorrhage) it may be appropriate to use
   terlipressin or octreotide and, in the case of uncontrolled UGIB in an unstable
   patient, balloon tamponade may be necessary, e.g. Sengstaken-Blakemore,
   Minnesota or Linton-Nachlas tubes.
l  Patients with an UGIB might need to be admitted to a high-dependency unit or
   intensive care unit. This decision should be clinical and used in conjunction with
   the Rockall score.
l  Some hospitals have beds specifically for patients with an UGIB. Evidence
   suggests that patients with UGIB should be assessed and managed in
   dedicated units as their outcome is improved.
l  Emergency endoscopy should be available 24 hours a day in such units.
l  Note that patients with liver disease are a special case and have separate
   guidelines for management.
CASE I – GI BLEEDING
MANAGEMENT
Other Medication:
l Anticoagulants and antiplatelet agents should be stopped during
  the acute phase and restarted later only if there is a clear
  indication.
l Patients who have healed ulcers and were H. pylori negative and
  require aspirin or NSAIDs or COX2 inhibitors, should be given
  concomitant PPI.
l SSRIs should be used in caution in patients at risk of UGIB or
  who have had a previous UGIB (especially if other drugs such as
  aspirin or NSAIDs are used).
l Corticosteroids will also need to be used carefully and probably
  with concomitant PPI in high-risk patients or those on high
  doses.
CASE J
CASE J. ECTOPIC
PREGNANCY
l   An ectopic pregnancy is one that occurs
    anywhere outside the uterus
l   By far the commonest place for ectopic
    pregnancy is the fallopian tubes. There are a
    few documented cases of viable pregnancy
    outside the uterus and tubes but as a general
    rule only an intrauterine pregnancy is viable.
CASE J. ECTOPIC
PREGNANCY
Risk factors
l  Pelvic inflammatory disease may cause complete tubal occlusion or delay the
   transport of the embryo so that implantation occurs in the tube. Adhesions from
   infection and inflammation from endometriosis may play a part.
l  Ectopic pregnancy has been reported in tubes that have been divided in a
   sterilisation operation and where they have been reconstructed to reverse one.
l  Ectopic pregnancy has been reported in the treatment of infertility
l  Right sided tubal pregnancy is commoner than on the left. This is thought to be
   from spread of infection from appendicitis.
l  The ability of the tube to expand increases from medially to laterally. Hence a
   more lateral implantation will present later as either pain or rupture.
l  Where an IUCD or progestogen-only oral contraceptives, including emergency
   contraception fails, the risk of a pregnancy being ectopic is greater than with
   other forms of contraception. Depot and implant contraception may not have the
   same risks. Ectopic pregnancy has been reported with implant contraception
   with etonogestrel (Implanon™) but appears rare.
l  An IUCD, being a foreign body with threads hanging into the vagina, increases
   the risk of infection. It is effective at preventing intrauterine pregnancy but
   probably ineffective at preventing pregnancy at other sites. Therefore, if
   pregnancy occurs with an IUCD in situ consider ectopic pregnancy
CASE J. ECTOPIC
PREGNANCY
PRESENTATION
30% of ectopics present before a period has been missed
l The first symptom is usually pain. This may be left or right iliac fossa
  pain or it may be central and suprapubic. If vaginal bleeding occurs it is
  much less significant than the pain.
  There may be a missed period and signs of pregnancy, perhaps even a
  positive pregnancy test.
l There may be a history of a previous ectopic pregnancy. After one
  ectopic pregnancy the chance of another in the other tube is much
  increased.
l If the ectopic pregnancy has ruptured, bleeding is profuse and there
  may be features of hypovolaemic shock including feeling dizzy on
  standing. Most bleeding will be into the pelvis and so vaginal bleeding
  may be minimal and misleading.
l Recent CEMACH reports have repeatedly emphasised the importance
  of diarrhoea and vomiting as a possible, atypical clinical presentation of
  ectopic pregnancy.
CASE J. ECTOPIC
PREGNANCY
Examination
l There may be some tenderness in the suprapubic region to left or right
  of the midline.
l If bleeding has started there may be peritonism and signs of an acute
  abdomen.
l There may be signs of early pregnancy such as fullness and tenderness
  of the breasts.
l Bimanual vaginal examination may reveal a tender fullness of one
  adnexum but some authorities recommend that this should not be done
  as the examination may rupture the tubal pregnancy.
l There is evidence that vaginal examination in suspected ectopic
  pregnancy adds nothing to the clinical picture and so should be avoided.
  5 The cited paper is just one of many reaching a similar conclusion.
l A check must be made for signs of blood loss. If there is hypovolaemic
  shock, resuscitation and transfer to hospital must occur without delay.
CASE J. ECTOPIC
PREGNANCY
Investigation
l The most accurate method to detect a tubal
  pregnancy is transvaginal ultrasound. Its availability
  improves management.
l Quantitative assessment of hCG levels is of value in
  confirming pregnancy and follow up if there is
  medical or conservative management.
l If hCG is below 1000 units and ultrasound has failed
  to locate an intrauterine or tubal pregnancy it is
  called a pregnancy of unknown location.
CASE J. ECTOPIC
PREGNANCY MANAGEMENT
l   Admit as an emergency if the diagnosis of ectopic pregnancy is
    considered a possibility. A bedside pregnancy test should be
    performed on all women of childbearing age presenting with
    lower abdominal pain where pregnancy is even the remotest
    possibility.
l   Expectant Management in hospital
    l Clinically stable patient, HCG<1000 and falling
l   Medical Management
    l Haemodynamically stable and initial HCG<3000
    l IM Methotrexate
    l Need Reliable contraception for 3months after
    l 10% need surgical intervention
l   Surgical Management
CASE J. ECTOPIC
PREGNANCY MANAGEMENT
Prognosis
l The risk of another ectopic pregnancy is about 10 to 20%
l The chance of subsequent intrauterine pregnancy is about 55 to 60%


Prevention
l Ectopic pregnancy does not occur in normal tubes, so prevention is
   based on avoiding the cause of damaged tubes
   l   This includes avoiding promiscuity and activities that predispose to pelvic
       inflammatory disease and the early diagnosis and treatment of appendicitis.
   l   That is not to say that all PID is sexually transmitted but many of the
       infecting organisms, including Chlamydia spp. are usually spread by that
       route.
   l   Routine screening of asymptomatic people for chlamydia may reduce the
       incidence of ectopic pregnancy, but this is yet to be proved.

				
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