Glassgow Coma Score/Scale

Hemoptysis Vs Hematemasis

Hemoptysis:

1- Its related to the cough precedes hemorrhage.

2- Blood frothy from admixture with air.

3- Sputum Bright red in color and may be stained for days.

4- History suggests respiratory diseases.

5- It confirmed by bronchoscopy.




Hematemasis:

1- Its related to the Nausea and vomiting precede hemorrhage.

2- It is generally airless.

3- Blood often alter in color by admixture with gastric contents, usually dark red or brown.

4- Previous history relate to the indigestion.

5- It is confirmed by gastroscopy.

Abdominal Pain

Definition: (Acute Abdomen)

This is a term used to define a group of abdominal conditions in which early surgical treatment must be considered.

Few medical conditions mimic surgical conditions and sometime un-necessary surgery is performed e.g;
Some patient with myocardial infarction just present with epigastric pain and vomiting.
Patient of diabetes ketoacidosis or porphyria may present with abdominal pain.



Cases in Surgical Emergency present with abdominal pain:

Pain due to Inflammation:
Appendicitis.
Cholecystitis.
Pancreatitis.
Intra-abdominal abscess.
Pelvic inflammation disease.

Pain due to Perforation:
Peptic Ulcer.
Ovarian Cyst.

Pain due to Vascular Ischemia:
Ruptured aortic aneurysm.
Mesenteric infarction.

Pain due to Obstruction:
Intestinal Obstruction.
Ureteric Colic.



Cases in Medical Emergency present with Abdominal pain:

Referred pain:
Myocardial Infarction.
Pneumonia.

Metabolic Causes:
DKA.
Lead poisoning.

Functional Gastrointestinal Disorders:
Irritable Bowel Syndrome.

Renal Causes:
Acute pyelonephritis

Hematological Causes:
Sickle cell crisis.
Hemophilia.
Purpura.

Vasculitis:
Embolic.

Mechanism of Abdominal pain:

1. Visceral pain.
2. Referred pain.
3. Miscellaneous.

1. Visceral pain:

Irritation or Inflammation of peritoneum.

Vascular Insufficiency.

Spasm of hallow viscus.

Stretching of capsule of solid organs.

Ulceration of tissues.

2. Referred pain:

From the chest.

From the vertebral column.

From the Gonads.

3. Miscellaneous:

Metabolic disorders.

Psychogenic disturbances.

Cerebral Vascular Accident (CVA)

Stroke:
Definition:

Stroke is an acute brain disorder of vascular origin accompanied by neurological dysfunction that persists for longer than 24 hours.
The neurological dysfunction can be Focal and Global.

Focal; which is typical of vascular occlusion.
Global; it can occur when vascular rupture leads to hemorrhage and mass effect.

Classification of Stroke:
It can classified according to the different causes;

1. Ischemic.
2. Hemorrhagic.

1. Ischemic Stroke:

Shock

Definition:
It is a systemic state of low tissue perfusion, which inadequate for normal cellular respiration, with insufficient delivery of oxygen and glucose, cell switch from aerobic metabolism to anaerobic metabolism.
Pathophysiology:

• Cellular.
• Microvascular.
• Systemic.
• Ischemia-reperfusion syndrome.

Cellular: As perfusion of tissues reduced, the respiration switch from aerobic to anaerobic respiration, the end product of anaerobic respiration is not carbon-dioxide while it is lactic acid that cause metabolic acidosis.

Microvascular: As tissue ischemia progresses, changes in local milieu result in activation of the immune and coagulation system.

Systemic: There are many system involves;

CVS; Tachycardia, Decreased Blood pressure.

Respiratory system; Metabolic acidosis that cause respiratory alkalosis , reduced CO2 lead to Hyperventilation.

Renal System; Decreased perfusion pressure in the kidney leads to reduced filtration at the glomerulus and a decreased urine output.

Endocrine; Activation of sympathetic system.

Ischemia-reperfusion syndrome:

During the period of Ischemia, hypoperfusion, cellular and organ damage progresses because of direct effects of tissue hypoxia and local activation of inflammation.

Classification of Shock:

1. Hypovolaemic Shock.
2. Cardiogenic Shock.
3. Obstructive Shock.
4. Distributive Shock.
5. Endocrine Shock.
6. Anaphylatic Shock
7. Neurogenic Shock.
8. Septic Shock.

Classification of Shock

Severity of Shock:

• Compensated Shock.
• Decompensated Shock.
• Mild Shock.
• Moderate Shock.
• Severe Shock.

Multiple Organ failure Due to Shock:

Multiple organ failure is defined as two or more failed organ systems.

There is no specific treatment for multiple organ failure.

Management is by supporting organ system with ventilation, cardiovascular support and haemofiltration/ Dialysis until there is recovery of organ functions.

Effects of organ failure;

Lungs                           Acute respiratory distress syndrome (ARDS).

Kidney                         Acute Renal Insufficiency.

Liver                             Acute Liver Insufficiency.

Clotting                         Coagulopathy.

Cardiac                           Cardiovascular Failure.

Management of Shock:

Hepatic Failure

Definition:
It occur due to severe cause of hepatic encephalopathy.
Types of Hepatic Failure:

1. Fulminant hepatic failure.
2. Subfulminant hepatic failure.

1. Fulminant hepatic failure:

Defined as severe hepatic failure with development of hepatic encephalopathy within 8 weeks after the onset of acute liver disease.

Causes:

In the absence of evidence of pre-existing in chronic liver disease that also lead to hepatic encephalopathy.

2. Subfulminant hepatic failure:
It is term used when encephalopathy occur between 8 weeks and 6 months after the onset of acute liver disease and carries an equally poor prognosis.
Causes:
About 70% cases are caused  by acute viral hepatitis.
50% due to hepatitis B.
Other causes are hepatitis A. E & D.

Clinical Features:
Jaundice.
Hepatic encephalopathy.
Small live on examination.

Investigation:
Aminotransferases.
Prothrombin time.
Decreased Coagulation Factors.
Electrocardiography.

* Liver biopsy is contraindicated.

Management:

1. Hepatic Encephalopathy.
2. Cerebral Edema.
3. Nutritions.
4. Cardiovascular functions.
5. Hemorrhage.
6. Infections.
7. Renal failure.
8. Acetylcysteine.
9. Liver Transplantaion.

1. Hepatic Encephalopathy:

It occur due to nitrogenous substances e.g. Ammonia it enters in portal circulation that by-pass the liver and lead to cerebral dysfunction.

* Because liver becomes unable to detoxify them.

2. Cerebral Edema:

It is major cause of the death in Hepatic failure.

Its due to signs present of Increased Intracranial Pressure (ICP).

3. Nutitions:

Maintain glucose and other diet balance.

4. Cardiovascular functions:

To maintain the blood pressure, pulse and urine output.

5. Hemorrhage:

Impaired homeostasis due to failure of coagulation factor production can result in bleeding from any site especially from GIT.

* It should need to manage by Different drugs.

6. Infection:

For infection use the broad spectrum drugs.

7. Renal failure:

Perform Dialysis, if there is renal failure.

8. Acetylcysteine:

It is an anidot of Paracetamol (Local Name Pk)

It is helpful for managing Liver / Hepatic failure.

9. Liver Transplantation:

It is perform at the end stage of Hepatic failure.

Thyroid Crisis

Definition:
Thyroid crisis is a medical emergency in which there is rapid deterioration of thyrotoxicosis.
Clinical Findings:
Hyperpyrexia.
Severe tachycardia.
Nausea.
Vomiting.
Diarrhea.
Dehydration.
Extreme restlessness.
Precipitating Factors:
Stress.
Infection.
Surgery in the unprepared patient.
Radioiodine therapy.

Management:
Propranolol - 0.5-2 mg IV 4 hourly.
or
20 - 120 mg orally 6 hourly.

Carbimazole - 25 mg 6 hourly.

Iodine - given 1 hour later as Lugol's solution/ sodium iodine.

Steroids - Hydrocortisone 50 mg 6 hourly.

* Aspirin should be avoided.

Types of Thyroid Crisis:

• Toxic Solitary Thyroid Nodules.
• Toxic Multinodular Goiter.
• Subacute Thyroiditis.
• Hashimoto's Thyroiditis.

Hospital Acquired Pneumonia

Definition:

The Hospital acquired pneumonia (HAP) or nosocomial pneumonia is said to be any pneumonia that can occur to the patient in a hospital at least 48–72 hours after admission.
It is usually caused by a bacterial infection, instead of a viral infection.
HAP is the second most common nosocomial infection (urinary tract infection is the most common) and accounts for 15–20% of the total.
HAP typically lengthens a hospital stay by 1–2 weeks.

Sign & symptoms:

Fever > 37.8 °C (100 °F).
Sputum Purulent.
Leucocytosis > 10.000 cells/μl.

Types:

Bacterial pneumonia;
The majority of cases related to various gram-negative bacilli and S.aureus,.
Usually of the MRSA type.
Others are Haemophilus spp.
In the ICU results were S.aureus(17.4%).
P.aeruginosa (17.4%).
Klebsiella pneumoniae.
Enterobacter spp. (18.1%),.
Haemophilus influenzae (4.9%).[1]
Viral pneumonia;
influenza and respiratory syncytial virus.
In the immunocompromised host, cytomegalovirus- cause 10-20% of infections

Diagnosis:
In respiratory insufficiency; chest X-Ray (CXR).
Increasing leucocyte count.
In case of pleural effusion thoracentesis; is performed for examination of pleural fluid.

Arterial Blood Gases (ABGs)

Definition:
Measurement of PaCO2 and PaO2 and H+ Conc. in arterial blood is valuable in assessment of hypoxemia or acid-base balance in respiratory failure and asthama.

Procedure:
Heparinize syringe with 0.1 ml heparin to prevent clot formation.
Draw blood from radial or brachial or femoral artery.
The sample should be immersed in ice bag immediately to prevent metabolism that can reduce PaO2 and increase PaCO2.

Normal values:
PH: 7.35 - 7.45
PaO2: 75 - 100 mm Hg
PaCO2: 35 - 45 mm Hg
HCO3: 24 - 28 mmol/L
O2 saturation: 95 - 100%

Types:
Respiratory Acidosis.
Respiratory Alkalosis.
Metabolic Acidosis.
Metabolic Alkalosis.

1- Respiratory Acidosis:
PH  < 7.35
PaCO2 increases > 45 mm Hg
HCO3 < 24 mmol/L

* If PH is normal, HCO3 is > 28 mmol/L, then it will be compensatory Respiratory Acidosis.

2- Respiratory Alkalosis:
PH > 7.45
PaCO2 < 35 mm Hg
HCO3 is normal or > 28 mmol/L

3- Metabolic Acidosis:
PH  < 7.35
PaCO2  is normal or < 35 mm Hg
HCO3 < 22 mmol/L

*  If PH is normal, PaCO2 is < 35 mm Hg, then it will be compensatory Metabolic Acidosis.

4- Metabolic Alkalosis:

PH > 7.45
PaCO2  35 - 45 mm Hg
HCO3 is > 28 mmol/L

Mechanical Ventilation

Definition:
When Patient fails to improvement in breathing by other measures, they should need oxygen therapy by Some respiratory support with mechanical ventilation, that improves the elimination of CO2.

Types of Mechanical Ventilation:
There are two types of mechanical ventilation;

• Non- Invasive mechanical ventilation.
• Invasive mechanical ventilation.

1- Non- Invasive mechanical ventilation:
In NIMV respiration is supported with face mask or nasal cannula and Endotracheal intubation avoided.
In this, Patient should be conscious, cooperative and be able to breath spontaneously and cough effectively by him or her self.
This Technique is commonly performed in COPD and Pneumonia.
2- Invasive mechanical ventilation:
In IMV Endotracheal tube is passed.
Patient may require;
* Full support and Partial support ventilator.
Full support Ventilator:
In this, all respiration controlled by ventilator.
In this case, Ventilator does not allow the spontaneous breathing.
Patient deeply sedative with short acting IV general anesthesia and paralyzed with muscles relaxant.
Partial support ventilator:
In this, all respiration does not controlled by ventilator, while patient also have his/her own effort.
It does not require deeply sedation or paralyses with muscles relaxant.

Indications:
Respiratory failure (Type II) that does not response to the medical treatment.
Head Injury- Patient have altered in mental status, and it controlled hyperventilation that reduce the Intra-cranial pressure.
Chest Injury- Flail chest, Pneumothorax and Hemothorax etc that reduces the breathing.
Severe Pulmonary edema.

Complications:
Tube insertion in one lung cause collapse of other lung.
Ventilator can induce the lung injury that leads to lungs infection.
It can cause Nosocomial, Hospital Acquired Pneumonia )HAP).
Abdominal Distention.
Fall in cardiac output (CO) due to positive pressure in lungs and thorax that reduce the venous return.