COMLEX LEVEL 2
WWW.AudioLearn.com
TABLE OF CONTENTS Preface........................................................................................................ 1 About the COMLEX 2 Examination ............................................................. 1 Chapter One: Emergency Medicine ............................................................. 1 Chest Pain ........................................................................................................................ 1 Acute Coronary Syndromes ............................................................................................. 2 Cardiorespiratory Arrest .................................................................................................. 4 Hypertensive Emergencies .............................................................................................. 5 Airway and Ventilation Emergencies .............................................................................. 6 Dyspnea ............................................................................................................................ 8 Asthma Emergencies ....................................................................................................... 9 COPD Exacerbations........................................................................................................ 9 Respiratory Failure ........................................................................................................ 10 Stroke ............................................................................................................................. 13 Status Epilepticus ...........................................................................................................17 Syncope .......................................................................................................................... 18 Loss of Consciousness or Coma ..................................................................................... 19 Headache Emergencies .................................................................................................. 22 Hypoglycemia ................................................................................................................ 22 Hyperglycemia ............................................................................................................... 23 Sepsis .............................................................................................................................. 25 Anaphylaxis .................................................................................................................... 27 Overdoses ....................................................................................................................... 28
Abdominal Pain ............................................................................................................. 29 Gastrointestinal Bleeding .............................................................................................. 31 Hematuria ...................................................................................................................... 32 Genitourinary Infections ............................................................................................... 33 Early Pregnancy Loss ..................................................................................................... 34 Pelvic Pain ...................................................................................................................... 35 Obstetrical Emergencies ................................................................................................ 36 Assessing Suicidality ...................................................................................................... 37 Behavioral Emergencies ................................................................................................ 38 Key Takeaways ............................................................................................................... 41 Quiz ................................................................................................................................ 42 Chapter Two: Family Medicine .................................................................. 46 Well Child Examination ................................................................................................. 46 Anemias .......................................................................................................................... 48 Bleeding Disorders ......................................................................................................... 49 Deep Vein Thrombosis................................................................................................... 51 Allergy Management ...................................................................................................... 52 Menstrual Difficulties .................................................................................................... 54 Contraceptive Counseling .............................................................................................. 57 Incontinence .................................................................................................................. 58 Chronic Renal Disease ................................................................................................... 60 GERD ............................................................................................................................. 61 Functional Dyspepsia..................................................................................................... 62 Irritable Bowel Syndrome .............................................................................................. 63
Acute and Chronic Hepatitis.......................................................................................... 65 Malabsorption ................................................................................................................ 67 Addison Disease ............................................................................................................. 68 Cushing Syndrome ......................................................................................................... 70 Hypothyroidism ............................................................................................................. 70 Hyperthyroidism .............................................................................................................71 Diabetes Mellitus ........................................................................................................... 72 Osteoporosis................................................................................................................... 74 Male Hypogonadism ...................................................................................................... 75 Strains and Sprains ........................................................................................................ 76 Stress Fractures.............................................................................................................. 77 Carpal Tunnel Syndrome ............................................................................................... 77 Osteoarthritis ................................................................................................................. 78 Fibromyalgia .................................................................................................................. 79 Benign Skin Lesions .......................................................................................................80 Skin Cancers ................................................................................................................... 81 Skin Burns ...................................................................................................................... 84 Psoriasis ......................................................................................................................... 87 Atopic Dermatitis ...........................................................................................................88 Alopecia .......................................................................................................................... 90 Vitiligo ............................................................................................................................ 92 Cellulitis ......................................................................................................................... 93 Impetigo ......................................................................................................................... 93 Acute Otitis Media ......................................................................................................... 94
Sinusitis .......................................................................................................................... 95 Sore Throat..................................................................................................................... 96 Asthma Management ..................................................................................................... 97 Key Takeaways ............................................................................................................... 99 Quiz ...............................................................................................................................101 Chapter Three: Health Promotion and Disease Prevention ..................... 104 Risk Assessment........................................................................................................... 104 Cancer Risk Factors ..................................................................................................... 106 Depression Risk Factors ............................................................................................... 112 Screening for Disease .................................................................................................... 112 Tobacco Abuse Counseling ........................................................................................... 114 Nutritional Counseling ................................................................................................. 117 Exercise Prescriptions................................................................................................... 118 Obesity Management .................................................................................................... 121 Substance Abuse Intervention ..................................................................................... 124 Care of Immigrants ...................................................................................................... 126 Key Takeaways ............................................................................................................. 132 Quiz .............................................................................................................................. 133 Chapter Four: Internal Medicine ............................................................ 136 Atherosclerosis ............................................................................................................. 136 Dyslipidemia ................................................................................................................ 138 Management of Hypertension ..................................................................................... 140 Arrhythmia Management ............................................................................................ 142 Heart Failure ................................................................................................................ 145
COPD Management ..................................................................................................... 147 Peptic Ulcer Disease..................................................................................................... 148 Inflammatory Bowel Diseases ..................................................................................... 150 Diverticulosis/Diverticulitis ........................................................................................ 152 HIV Disease.................................................................................................................. 153 Disseminated Intravascular Coagulation .....................................................................155 Management of Hematological Malignancies ............................................................. 156 Rheumatoid Arthritis ................................................................................................... 159 Acute Kidney Injury ...................................................................................................... 161 Fluid and Electrolyte Disorders ................................................................................... 162 Acid-Base Disorders..................................................................................................... 166 Key Takeaways ............................................................................................................. 168 Quiz .............................................................................................................................. 169 Chapter Five: Neurology .......................................................................... 172 Brain Infections ............................................................................................................172 Encephalitis...................................................................................................................173 Brain Abscesses .............................................................................................................175 Delirium ........................................................................................................................175 Dementias ..................................................................................................................... 177 Brain Cancer ................................................................................................................ 178 Myelination Disorders ................................................................................................. 179 Neurofibromatosis ....................................................................................................... 182 Myasthenia Gravis ....................................................................................................... 184 Amyotrophic Lateral Sclerosis ..................................................................................... 185
Peripheral Neuropathy ................................................................................................ 186 Chronic Pain Syndromes ............................................................................................. 188 Parkinson Disease ........................................................................................................ 189 Sleep and Wakefulness Disorders ............................................................................... 190 Stroke Rehabilitation .................................................................................................... 191 Key Takeaways ............................................................................................................. 193 Quiz .............................................................................................................................. 194 Chapter Six: Obstetrics/Gynecology ......................................................... 197 Family Planning Issues ................................................................................................ 197 Routine Obstetrical Care ............................................................................................. 199 High-Risk Pregnancy Care........................................................................................... 201 Labor and Delivery.......................................................................................................204 Newborn Evaluation and Care ...................................................................................... 211 Polycystic Ovarian Syndrome ...................................................................................... 212 Endometriosis .............................................................................................................. 214 Anovulation or Ovulatory Dysfunction ....................................................................... 216 Menopause Management..............................................................................................217 Female Infertility ......................................................................................................... 218 Abnormal Uterine Bleeding ......................................................................................... 219 Key Takeaways ............................................................................................................. 221 Quiz .............................................................................................................................. 222 Chapter Seven: Osteopathic Principles and Practice ............................... 225 Somatic Dysfunction .................................................................................................... 225 Osteopathic Techniques ............................................................................................... 228
Regional Diagnoses ...................................................................................................... 232 Cranial Diagnoses ........................................................................................................ 232 Cervical Diagnoses ....................................................................................................... 234 Thoracic, Rib, and Diaphragm Diagnoses ................................................................... 237 Lumbar Diagnosis ........................................................................................................240 Sacrum and Pelvis Diagnosis ....................................................................................... 242 Extremity Diagnosis..................................................................................................... 245 Systemic Disease in Osteopathy .................................................................................. 255 Head and Neck Issues .................................................................................................. 255 Cardiology .................................................................................................................... 257 Pulmonology ................................................................................................................ 258 Gastroenterology .......................................................................................................... 259 Urology and Gynecology ..............................................................................................260 Obstetrics ..................................................................................................................... 261 Pediatrics...................................................................................................................... 263 Hospitalized and Postoperative Patients ..................................................................... 264 Key Takeaways ............................................................................................................. 265 Quiz .............................................................................................................................. 266 Chapter Eight: Pediatrics ........................................................................ 270 Well Child Care ............................................................................................................ 270 Diseases of Infancy ...................................................................................................... 272 Pediatric Behavioral Issues .......................................................................................... 275 Congenital Heart Disease ............................................................................................ 277 Childhood Respiratory Diseases .................................................................................. 282
Childhood GI Disorders ............................................................................................... 284 Cystic Fibrosis .............................................................................................................. 292 Chromosomal or Gene Abnormalities ......................................................................... 294 Childhood GU Problems .............................................................................................. 296 Bone Diseases in Children ........................................................................................... 298 Child Abuse and Neglect ............................................................................................. 300 Craniofacial and Musculoskeletal Anomalies ............................................................. 302 Endocrine Disorders .................................................................................................... 305 Learning and Developmental Disorders .....................................................................309 Key Takeaways ............................................................................................................. 313 Quiz .............................................................................................................................. 314 Chapter Nine: Psychiatry ......................................................................... 317 Anxiety Disorders .........................................................................................................317 Trauma and Stress-related Disorders ......................................................................... 320 Dissociative Disorders ................................................................................................. 321 OCD .............................................................................................................................. 324 Gender Dysphoria ........................................................................................................ 327 Impulse Control and Conduct Disorders..................................................................... 328 Depressive and Bipolar Disorders ............................................................................... 329 Personality Disorders................................................................................................... 333 Schizophrenia and Psychotic Disorders ...................................................................... 339 Somatic Symptom Disorders ....................................................................................... 341 Substance Abuse and Addiction .................................................................................. 343 Eating Disorders .......................................................................................................... 345
Paraphilias ................................................................................................................... 348 Key Takeaways ............................................................................................................. 351 Quiz .............................................................................................................................. 352 Chapter Ten: Surgery .............................................................................. 355 Preoperative Care......................................................................................................... 355 Breast Surgery .............................................................................................................. 357 Gastrointestinal Surgery .............................................................................................. 365 Hepatobiliary Surgery .................................................................................................. 368 Hernias ......................................................................................................................... 369 Skin and Subcutaneous Tissues ................................................................................... 372 Hysterectomy ............................................................................................................... 373 Key Takeaways ............................................................................................................. 376 Quiz .............................................................................................................................. 377 Summary ................................................................................................ 380 Course Questions and Answers ............................................................... 383 Answers to Quiz ...................................................................................... 465 Chapter One ................................................................................................................. 465 Chapter Two ................................................................................................................. 467 Chapter Three .............................................................................................................. 468 Chapter Four ................................................................................................................ 470 Chapter Five ................................................................................................................. 471 Chapter Six ................................................................................................................... 472 Chapter Seven .............................................................................................................. 473 Chapter Eight ............................................................................................................... 474
Chapter Nine ................................................................................................................ 475 Chapter Ten .................................................................................................................. 476 Course Questions ......................................................................................................... 477
PREFACE The purpose of this course is to prepare you, the osteopathy student, to pass the COMPLEX Level 2 Examination, which is necessary for you to be accepted into an osteopathic or allopathic residency program. This is the second of a three-level examination process. The examination you will take an entire day and will be divided into two four-hour segments. The main difference between the COMLEX Level 1 Examination and the COMLEX Level 2 examination is that the focus now is more on the clinical presentation and workup of disease processes with a smaller emphasis on management. Areas covered include emergency medicine, family medicine, internal medicine, osteopathic principles and practice, obstetrics and gynecology, pediatrics, psychiatry, health promotion and disease prevention, neurology, and psychiatry. Each of these is covered in order to give you a broad base of understanding of these topics. The main focus of chapter one in the course is to help you understand the different emergency department presentations you may encounter. There are many different disorders that present in this clinical setting, including cardiac emergencies, acute respiratory diseases, abdominal pain and GI bleeding, genitourinary diseases, neurological disorders, toxicology issues, endocrine emergencies, and behavioral emergencies. You should understand the different presentations of these conditions and how to evaluate and manage them. For this reason, these are presented as part of the chapter. Chapter two covers topics that are seen in a typical osteopathic family medicine practice. The primary care physician will deal with the well patient, patients with acute diseases, and patients who have chronic concerns or chronic conditions. Unlike those seen in internal medicine, most are not urgently life-threatening but will require long-term management with the primary care physician who recognizes the mind-body connection between many physical disorders. The focus of chapter three in the course is health promotion and the prevention of disease. As a healthcare provider, part of your job is to assess patients for their risk of
1
certain diseases, screen for early disease, and intervene in ways that promote health. In this chapter, we talk about nutritional counseling, tobacco cessation techniques, obesity management strategies, substance abuse intervention, and the different ways a provider must address the unique health concerns of a new immigrant to the US. Chapter four includes topics important to the practice of internal medicine. It involves the treatment of many chronic heart diseases, such as hypertension, atherosclerosis, cardiac arrhythmias, and heart failure, as well as lung diseases such as chronic obstructive pulmonary disease. Various gastrointestinal diseases are also covered, such as peptic ulcer disease, inflammatory bowel diseases, and diverticular disease. Acute kidney injury is discussed, as well as related disorders of electrolytes and acid-base disorders. The diagnosis and management of hematological malignancies, disseminated intravascular coagulation, and rheumatoid arthritis are also discussed. Chapter five in the course focuses on the main neurological diseases and disorders you might encounter. This is one of the main areas covered in the COMLEX 2 examination. Areas covered in this chapter include brain infections, delirium, dementia, and brain tumors. Less commonly seen diseases in the chapter are neurofibromatosis, myasthenia gravis, amyotrophic lateral sclerosis, and neuropathies. Sleep-wake disorders and stroke rehabilitation are also discussed. Chapter six is about obstetrics and gynecology, particularly those factors not involved in emergency care of family medicine. The normal obstetrical care is covered as well as the obstetrical care involved in high-risk pregnancies, normal labor and delivery, and delivery complications. The evaluation of the newborn after birth is also discussed. The different gynecological conditions, such as endometriosis, polycystic ovary syndrome, ovulatory dysfunction, infertility, and family planning are also covered as part of this chapter. Chapter seven in the course focuses on the different osteopathic principles and practice you will be evaluated on in the Comlex 2 examination. You will need to know what somatic dysfunction is and how to make the diagnosis as well as how to make a regional diagnosis. Other areas covered in the chapter include the different osteopathic
2
therapies you need to know about, such as cranial, thoracic, lumbar, and extremity treatments as well as systemic treatments used in osteopathic practices. The evaluation and management of pediatric disorders is the topic of chapter eight. It includes the care of the well child and of the common childhood problems. There are some childhood disease that are congenital and require treatment early in the child’s life. There are other genetic and chromosomal disorder that need management by the pediatrician. Children also have developmental disorders, behavioral problems, and issues related to child abuse or neglect that are covered as part of this chapter. Chapter nine in the course looks into the subject of psychiatry. There are numerous psychiatric disorders that have both genetic and environmental or psychosocial components. You should be able to identify the different disorders represented in the chapter, including trauma-related diseases, mood disorders, anxiety disorders, eating disorders, and psychosis. The diagnosis of nearly all psychiatric disorders involves a working knowledge of the Diagnostic and Statistical Manual of Mental Disorders, which is used to identify the different disorders mentioned in the chapter. The focus of chapter ten is surgery and surgical procedures. Preoperative assessment is discussed in the chapter as well as the many different surgical techniques performed by the general or specialist surgeon. These include the different breast surgeries, skin procedures, gastrointestinal and hepatobiliary surgeries, hernia repairs, and hysterectomies, some of which are done for medical reasons, while others are done because of cancer and the need for cancer resection as part of the treatment of the different malignancies.
3
ABOUT THE COMLEX 2 EXAMINATION The COMLEX Level-2 examination is actually two separate test you will take at two separate times. They are based, however, on the same material. The COMLEX-USA Level 2-CE examination is a cognitive evaluation. It assess what you know about several areas of clinical sciences that are a part of osteopathy. The COMLEX 2-CE examination is given in a single day with two four-hour blocks of time in which you are faced with clinical information for which a multiple-choice answer is expected. The COMLEX 2-CE examination is different from the COMLEX 1 examination because it emphasizes the clinical rather than the basic sciences. You will apply what you know about osteopathic medical knowledge, patient care, osteopathic principles and practice, systems-based practice, communication, ethics, and professionalism. The COMLEX 2-CE examination is different from the COMLEX 2-PE examination only in the form the test is taken. The basic information you need to know for each examination is the same. In the COMLEX 2-PE examination, you will be given twelve vignettes and will be asked to apply what you know about obtaining a history and physical, workup of specific presentations, and treatment of the patient using osteopathic principles and practice. The COMLEX-USA Level 2-CE examination is based on ten core areas of osteopathic practice. These are emergency medicine, family medicine, health promotion and disease prevention, internal medicine, neurology, obstetrics/gynecology, osteopathic principles and practice, pediatrics, psychiatry, and surgery. There are 400 diverse questions related to the different clinical and patient presentations you will encounter in osteopathic practice. You will be asked to choose the correct answer out of five choices. A few will be computer-generated audiovisual-based questions. During the test, you will be allowed two four-hour blocks of time, with three optional breaks and a 40-minute lunch break. As mentioned, the COMLEX Level 2-PE examination is a practical examination in which you will, through following twelve hypothetical patient scenarios, demonstrate the 1
practical knowledge you have gained in your osteopathic training. It is not actually based on different material from the COMLEX 2-CE examination but augments this examination through real-life scenarios. In this examination, there is a humanistic domain, focused on physician-patient communication, interpersonal skills, and professionalism. There is also a biomedical/biomechanical domain, focused on history-taking skills, physical examination skills, osteopathic principles and manipulative treatment, and skills in documentation. Your ability to synthesize clinical findings, make a differential diagnosis, and formulate a treatment plan will be assessed. You will be allowed 14 minutes per case along with 9 additional minutes to document your findings in a SOAP (Subjective Objective Assessment Plan) format. While there are two distinct dimensions involved in the COMLEX 2-CE examination, these are seamless throughout the test. In dimension 1, there are seven competency domains that represent the foundations of osteopathic medicine. These are the domains represented: •
Osteopathic Principles, Practice, and Manipulative Treatment
•
Osteopathic Patient Care and Procedural Skills
•
Application of Knowledge for Osteopathic Medical Practice
•
Practice-based Learning and Improvement in Osteopathic Medical Practice
•
Interpersonal and Communication Skills in the Practice of Osteopathic Medicine
•
Professionalism in the Practice of Osteopathic Medicine
•
Systems-based Practice in Osteopathic Medicine
Dimension 2 involves the clinical presentation of patients who might present for care to an osteopathic physician. There are ten clinical presentations, including the following: •
Community Health and Patient Presentations Related to Wellness
•
Human Development, Reproduction, and Sexuality
•
Endocrine System and Metabolism
2
•
Nervous System and Mental Health
•
Musculoskeletal System
•
Genitourinary/Renal System and Breasts
•
Gastrointestinal System and Nutritional Health
•
Circulatory and Hematologic Systems
•
Respiratory System
•
Integumentary System
When you take the examination, you will be given a raw score that is converted into a standard score, for which the passing grade is designated at 400 points. Each test question is given equal weight. Ultimately, you will be given a pass or fail determination. There are some test questions included in the examination that are solely for research purposes that will not be included in the candidate score. A percentile score will not be given, although you will be able to convert your three-digit score into a percentile rank if you choose to do this.
3
CHAPTER ONE: EMERGENCY MEDICINE The main focus of this chapter is to help you understand the different emergency department presentations you may encounter. There are many different disorders that present in this clinical setting, including cardiac emergencies, acute respiratory diseases, abdominal pain and GI bleeding, genitourinary diseases, neurological disorders, toxicology issues, endocrine emergencies, and behavioral emergencies. You should understand the different presentations of these conditions and how to evaluate and manage them. For this reason, these are presented as part of the chapter.
CHEST PAIN Many people will come into the emergency department with chest pain; most of these will reflect benign and not life-threatening problems. Nevertheless, it should never be ignored. Sources of chest pain can include the chest wall, heart, esophagus, lungs, and great vessels. Thoracic pain is generally felt mainly in the chest but can refer to anywhere between the mid-abdomen to the upper arms. Visceral pain is often felt as “discomfort” rather than true pain, while somatic pain is sharp or aching. Life-threatening causes of chest pain that need to be considered include acute coronary syndrome, pulmonary embolism, esophageal rupture, tension pneumothorax, and aortic dissection. These are not always the most common, however. The most common chest pain causes are pleural disease, chest wall inflammation, GERD, peptic ulcer disease, esophageal spasm, and acute coronary syndrome. The history should be important to making the diagnosis. Characteristics of the pain, inciting events, and relieving factors should be asked about as well as other coexisting symptoms, such as nausea, dyspnea, syncope, cough, chills, palpitations, or fever. Possibly related things you should ask about include leg pain and swelling, chronic weight loss, malaise, and ongoing weakness. Risk factors for heart disease should be included, such as dyslipidemia, diabetes, tobacco use, cerebrovascular disease, and
1
hypertension, as well as a positive family history of MI. Drug use, particularly cocaine use, can contribute to vasospastic heart disease. In your examination, look for vital signs, body mass index, cyanosis, diaphoresis, neck vein distention, adenopathy, lung sounds, heart sounds, carotid bruits, herpes zoster lesions, abdominal and chest tenderness, leg swelling and edema. You should be concerned if you see abnormalities of the vital signs, hypoperfusion, dyspnea, hypoxemia, new heart murmurs, pulsus paradoxus, or asymmetry of the lung sounds or pulse. The exacerbation and relief of the pain can help with the diagnosis. Pain with exercise that relieves itself with rest can be anginal pain. Nocturnal pain can be vasospasm, acute coronary syndrome, or heart failure. Pain when lying down can be GERD-related pain. Tenderness by itself does not rule out coronary causes because up to 15 percent of cardiac patients have chest wall tenderness. Nitroglycerin can relieve MI pain, biliary pain, and esophageal pain. All patients should have pulse oximetry, chest x-ray, and ECG testing. With possible coronary pain, serial ECGs are necessary. Troponin levels that are low rule out cardiac causes in most cases, although the level will not rise immediately after an occlusion. A normal pulse oximetry does not rule out a pulmonary embolism, if it is small. D-dimer testing, if normal, rules out a pulmonary embolism but, if high, does not prove one.
ACUTE CORONARY SYNDROMES All acute coronary syndromes come from a sudden obstructive event of a coronary artery. Depending on the degree of obstruction and its location, the diagnosis can be unstable angina, non-ST-segment elevation MI or NSTEMI, or ST-segment elevation MI or STEMI. Sudden cardiac death is another acute coronary syndrome. All patients, except in sudden death, will describe chest discomfort plus the possibility of nausea, vomiting, dyspnea, and diaphoresis. Unstable angina involves prolonged coronary pain at rest or increasing severity of previously stable angina. The patient may have transient ECG changes of any type but
2
will not have an elevation of the troponin or CK-MB level. Because this can easily lead to an MI, it should be considered serious. NSTEMI is a subendocardial myocardial infarction with positive enzymes but ECG changes revealing ST-segment depression and/or T wave inversion. STEMI will have a transmural MI with ST-segment elevation, new left bundle branch block and elevation of troponin and CK-MB elevation. Figure 1 shows the ECG changes in a STEMI:
Figure 1.
The majority of cases of acute coronary syndrome is an acute thrombus in a coronary artery that had prior atherosclerosis. Atheromas come from instability or inflammation of a stable plaque that activates platelets, leading to a blood clot in the vessel. Less common causes include embolism to a coronary artery, arterial vasospasm, and coronary artery dissection. Cocaine is the most common cause of vasospasm to the
3
coronary arteries. Dissection can be seen in connective tissue diseases, fibromuscular dysplasia, and pregnancy. The symptoms depend on the size and location of the obstruction. Pain is described as the urge to burp, discomfort, tearing pain, indigestion, pressure, burning, sharp, or stabbing. The degree of pain does not predict the size of the infarct. Complications you need to look out for include cardiac arrhythmias or conduction defects, heart failure, septal rupture, ventricular aneurysm, mural thrombosis, shock, valve dysfunction, and later, Dressler syndrome, which is post-MI pericarditis. Because the diagnosis is not always clear, serial enzymes and serial ECGs are necessary. The patient with a STEMI or evidence of ongoing pain, hypotension, or unstable arrhythmias should have immediate angiography. This can be delayed for a day or two In NSTEMI or unstable angina patients. The ECG is the most important diagnostic test for an MI. Cardiac makers include troponin T, myoglobin, troponin I, and CK-MB. Angiography is confirmatory and is paired with percutaneous coronary intervention, if necessary. All patients need aspirin, nitrates, and oxygen in the prehospital setting. In the ED, consider morphine for pain and dyspnea, antiplatelet drugs, anticoagulants, reperfusion drugs like TPA, and percutaneous intervention. Some patients will need coronary artery bypass surgery.
CARDIORESPIRATORY ARREST Cardiac arrest involves the lack of a perfusing rhythm such that organs are not perfused and death rapidly ensues. There is often little warning or no warning involved in the event, with nearly 90 percent of people dying of this type of event. There are distinct differences between a respiratory arrest and a cardiac arrest, although one generally leads quickly to the other. Almost all adults with an arrest will have a cardiac arrest first from some type of cardiac disease. Other causes include a major hemorrhage, traumatic event, or pulmonary embolism. Metabolic disturbances can rarely be a cause, including a drug overdose, leading to respiratory arrest. Infants and children have respiratory arrest first, due to 4
ventilation disturbances, such as drowning, SIDS, smoke inhalation, or airway obstruction, although trauma and poisoning can play a role. The diagnosis is largely clinical. There may be presyncopal symptoms, progressive loss of level of consciousness, or seizure. Many will have no warning whatsoever but will simply collapse. The diagnosis is made by the presence of pulselessness, unconsciousness, and apnea. Pupils will be unreactive within minutes of the event because of cerebral anoxia. The three rhythms most commonly seen are ventricle tachycardia, ventricular fibrillation, and asystole. Pulseless electrical activity is less commonly seen. Look at possible causes that could be treated, including hypoxia, hyperkalemia, acidosis, hypokalemia, hypothermia, hypoglycemia, tamponade, toxic ingestion, pulmonary embolism, MI, trauma, or tension pneumothorax. Survivability depends on whether the event happened in a hospital, was witnessed, was treated with early defibrillation, had early CPR, had a rhythm other than asystole, and receive good post-resuscitative care after the event has resolved.
HYPERTENSIVE EMERGENCIES Hypertensive emergencies in the emergency department are seen as severely high blood pressure readings along with evidence of damage to target organs, such as the eyes, brain, heart, and kidneys. Patients will sometimes present with myocardial ischemia, aortic dissection, renal failure, preeclampsia or eclampsia, pulmonary edema from heart failure, and hypertensive encephalopathy. Very high pressures cause transudation and exudation of blood plasma into the tissues. When it happens in the eyes, you see papilledema. When it happens in the brain, you see cerebral edema. Those with intracranial hemorrhage can have high blood pressure secondary and not causative of the hemorrhage so lowering the blood pressure could be harmful to the patient. A situation of hypertensive urgency happens with diastolic pressures of greater than 120 but no evidence of end organ damage except mild retinopathy. Emergency blood
5
pressure reduction with parenteral measures is not necessary but oral antihypertensives can be recommended. If there are symptoms, some of these will be confusion, seizures, stroke-like symptoms, shortness of breath, chest pain, and sometimes evidence of acute azotemia, such as nausea and lethargy. Fundoscopy will be crucial to the evaluation as well as a mental status evaluation, urinalysis, lung and heart examination, and jugular venous distention. Papilledema will be an early finding. Those with neurological symptoms need a CT of the head. ECG will show acute ischemia or ventricular hypertrophy. The goal is to reduce the mean arterial pressure by 20 to 25 percent in an hour or two using IV drugs like labetalol, nicardipine, nitroprusside, or fenoldopam. These drugs are helpful because they are titratable. It is not necessary to normalize the blood pressure acutely.
AIRWAY AND VENTILATION EMERGENCIES In most medical situations, except for cardiac arrest, airway management takes priority in an emergency setting. There are three steps. The first is clearing the upper airway of mucus or other obstruction. The second is using a mechanical device, such as an oropharyngeal airway or nasal airway to maintain an open passage. The third is assisting the patient in ventilations. Once ventilations are established, about six to eight milliliters per kilogram should be given per breath, along with a ventilatory rate of 8 to 10 breaths per minute. Even slower rates are recommended when air trapping is involved, such as COPD or asthma exacerbations. There are hemodynamic advantages to keeping the respiratory rate low. The head tilt-chin lift and jaw-thrust maneuvers will help maximize airway patency. In cases of possible cervical fracture, the jaw lift maneuver, which involves drawing the mandible forward, will help to open the airway. Dentures, blood, and secretions can be removed manually or can be removed through suction. A Magill forceps can remove deeper material.
6
True airway obstruction might involve subdiaphragmatic abdominal thrusts, also called the Heimlich maneuver. Chest thrusts are instead done on very obese or pregnant patients until the airway clears or until unconsciousness occurs. This is done by standing behind the patient with fists clenched around the upper abdomen. Upward thrusts are given repeatedly in order to clear the blockage. The unconscious patient with an obstructed airway is given CPR in order to increase the intrathoracic pressure. The oropharynx should be evaluated so that any foreign bodies can be removed with the fingers or with a Magill forceps. If the obstruction is below the vocal cords, the best way to remove the obstruction is to do CPR. Infants should not have the Heimlich maneuver but should be held prone and be given five back thrusts followed by five chest thrusts, also in the prone and head-down position. This should be done repetitively until the obstruction is relieved. Ventilation of the emergency patient can be done in several ways. Once an oropharyngeal airway or nasal airway is provided, a bag-valve-mask can be used, which ventilates the patient by providing firm pressure on the patient’s face so that air up to 100 percent inspired oxygen can be given. The biggest downside of this is that, if done for longer than five minutes, gastric distention can occur unless an NG tube is placed. A laryngeal mask airway can be used to secure an airway for ventilation. These avoid the necessity of getting a good facial seal and can allow either an NG tube or endotracheal tube to be passed through it. Its biggest advantage is that it can be used if the endotracheal tube cannot be effectively passed. Vomiting and aspiration can happen if the gag reflex is intact. It is a good bridging device before a definitive airway can be established. Endotracheal intubation can provide a definitive airway and will protect the airway. Pre-ventilation should involve several minutes of 100 percent oxygen. Other ways to ventilate the patient should always be available. A laryngoscope is used to visualize the cords so that the ET tube can be passed and later secured to the patient’s face. Suctioning prior to visualization may be necessary. Some patients will need vagolytic drugs, muscle relaxants, and sedatives if they are not completely unconscious. Use a
7
size 8-millimeter tube in adults unless it is clear this will not work because the lower airway resistance will reduce the work of breathing.
DYSPNEA Patients will present to the emergency department with the complaint of dyspnea, which involves uncomfortable or unpleasant breathing situations. It isn’t exactly clear how the phenomenon of dyspnea occurs. There may be areas of the midbrain that perceive this but it isn’t yet well-established. The most common cause of dyspnea are pneumonia, asthma, COPD, physical conditioning, and myocardial ischemia. Many with chronic lung diseases have dyspnea when their disease is worsened for some reason. In evaluating dyspnea, get an idea of its onset and exacerbating factors. Find out if they have dyspnea as a baseline symptom. Look for other supporting symptoms, such as fever, cough, chest pain, hemorrhaging, orthopnea, paroxysmal nocturnal dyspnea in heart failure, weight loss, night sweats, or sputum production. Important aspects of the past medical history include smoking history, risk factors for coronary artery disease, recent immobilization, or occupational exposures. The examination will focus primarily on the heart and lungs. Vital signs will look for things like tachypnea, tachycardia, hypoxia, and fever. A complete lung exam will look for abnormal lung sounds and airflow. Adenopathy should be looked for as well as neck veins for distention. Evaluate the conjunctiva for pallor and listen for extra heart sounds, heart murmurs, or muffled heart sounds. Concerning findings include agitation, confusion, or decreased level of consciousness, dyspnea at rest, use of accessory muscles, crackles in the lungs, palpitations, night sweats, weight loss, or chest pain. Wheezing mainly suggests COPD or asthma, while stridor represents upper airway obstruction. Crackles can be seen with lung disease or left heart failure. Leg swelling, when unilateral, indicates the possibility of a pulmonary embolism. Hyperventilation is a diagnosis of exclusion. In testing the patient with dyspnea, pulse oximetry should always be done. A chest x-ray should be done unless the diagnosis is clear, such as an asthma or COPD exacerbation. An ECG plus cardiac markers are done if a cardiac cause is possible. Deteriorating 8
patients should have an ABG evaluation. If there is a high risk of pulmonary embolism, CT angiography or ventilation/perfusion scanning should be done. D-dimer testing, if low, will rule out a PE.
ASTHMA EMERGENCIES Asthma exacerbation happens when a known asthmatic fails to have adequate control over their symptoms at home. Even though most patients have beta-2 agonist treatment at home, this can be given with a nebulizer along with ipratropium, an anticholinergic drug, to open the airways. Most patients will improve with systemic corticosteroid therapy. A peak expiratory flow meter can judge any improvement in airflow after treatment is given. Some patients can also receive subcutaneous epinephrine or terbutaline. The downside of these are cardiostimulatory effects, which can be uncomfortable or can produce increased stress on the heart. If the peak expiratory flow rate normalizes quickly after a bronchodilator is given, systemic corticosteroids are not given but should be used in all other circumstances. Any route of administration of these drugs is acceptable. Supplemental oxygen is only given for hypoxemia, while theophylline and magnesium sulfate are of questionable value. The patient should be hospitalized if there is no improvement, if there is evidence of respiratory fatigue, evidence of ongoing relapse after treatment, hypoxemia, or hypercarbia, which suggests respiratory failure. This means that an ABG may be necessary in order to evaluate the partial pressure of carbon dioxide in the blood, which is the best indicator of respiratory failure in the dyspneic statement. Some patients require noninvasive positive pressure ventilation or endotracheal intubation if they are at risk for hypoventilation.
COPD EXACERBATIONS COPD exacerbations involve acute or subacute worsening of COPD symptoms, leading to purulent sputum, increased cough, and/or increased dyspnea. After evaluating the patient with regard to their symptoms and physical findings, most patients require 9
supplemental oxygen, bronchodilator therapy, corticosteroids, antibiotics, and sometimes assistance with ventilations. Most of the time, the cause of the exacerbation is unknown, although smoking, air pollution, bacterial infections, and viral infections can all play a role. The uncomplicated patient can be managed as an outpatient. Those with other comorbidities, prior respiratory failure, respiratory acidosis, deteriorating respiratory function, or a new arrhythmia will require an ICU admission. Oxygen should be given, even if it worsens the hypercapnia because it minimizes the ventilation/perfusion mismatch. If hypercapnia is leading to respiratory failure, nasal prongs or a Venturi mask should be considered to better regulate the oxygen intake. Besides oxygen, the first treatment for a COPD exacerbation should be a short-acting beta-agonist, such as albuterol. Anticholinergics, like ipratropium, can also be inhaled. Interestingly, metered dose inhalers with spacers are just as good as nebulizer treatment. All but the mildest of cases should be treated with IV or oral corticosteroids. If there is purulent sputum, antibiotics should be given. The most effective initial antibiotics are trimethoprim/sulfamethoxazole, amoxicillin, and doxycycline, although sicker patients should be treated with a fluroquinolone, second generation cephalosporin, amoxicillin/clavulanate, or extended spectrum macrolides, such as clarithromycin or azithromycin.
RESPIRATORY FAILURE There are two kinds of respiratory failure. The first is acute hypoxemic respiratory failure, which involves severe hypoxemia that does not resolve with supplemental oxygen. The main cause is shunting of blood in areas of the lungs that are not aerating. The main causes of this are left ventricular failure, which fills the alveoli with fluid, increased permeability of the capillaries as in ARDS, or consolidation or blood in the alveoli, which keep them from aerating. In ARDS, there is inflammation of the lungs or systemically along with the release of cytokines that recruit inflammatory molecules and other factors that damage the capillary endothelium, disrupting the respiratory membrane so that the alveoli fill with
10
fluid. The alveoli and airways collapse and there is severe ventilation/perfusion mismatching. The cause may be from a direct lung injury or to indirect inflammation of the lungs from an extra-pulmonary source. The patient with ARDS will have restlessness, anxiety, altered level of consciousness, tachypnea, diaphoresis, tachycardia, and dyspnea. Crackles will be heard in almost all lung fields. A chest x-ray and ABGs will clarify the diagnosis. Figure 2 shows what ARDS typically looks like on chest x-ray:
Figure 2.
While oxygenation will not reverse the hypoxemia, it should be given. The rest of the treatment is directed at identifying and treating the underlying cause. Identify if the patient is hypervolemic and has high-pressure ARDS or low-pressure ARDS, as would be seen in pneumonia or sepsis.
11
The treatment may involve mechanical ventilation, if other ways of ventilating the patient are not possible. Positive pressure ventilation or PEEP will help reduce the ventilation/perfusion mismatch and will improve the oxygenation. The goal is to keep the airways open and the alveoli oxygenating so as to enhance oxygenation while the underlying process is treated. The other cause of respiratory failure is failure of ventilation, which leads to hypercapnia. There can be a decreased minute ventilation or an increase in dead-space ventilation that is not compensated for by increasing the ventilatory rate. There can be neuromuscular incompetence or excessive loads on the respiratory system that cannot be overcome by the patient’s respiratory drive. Hypercapnia from ventilatory failure causes respiratory acidosis. If this is severe, there will be vasoconstriction of the pulmonary arteries, vasodilation of the systemic vasculature, hyperkalemia, hypertension, decreased myocardial contractility, and increased risk of arrhythmias. For patients who are head injured, the cerebral vasculature will dilate, which will increase the intracranial pressure. If the kidneys do not have time to compensate, the acidosis can be severe. There are many possible causes of this type of ventilatory failure. Anything that affects neuromuscular transmission or muscle strength will contribute to failure. Impaired respiratory drive, increased chest wall elastic loads as is seen in obesity or pneumothorax, increased lung elastic loads, or increased resistance to airway flow can all contribute to ventilatory failure. Most patients will exhibit some type of dyspnea with an increase in use of accessory muscles, anxiety, gasping breathing, tachycardia, tachypnea, diaphoresis, poor tidal volume, and anxiety. There will be CNS changes, such as significant confusion, decreased level of consciousness, and coma. The patient should have a chest x-ray, confirmatory arterial blood gases, and continued pulse oximetry. Acidosis and elevated CO2 levels confirm the diagnosis. The patient with neuromuscular failure may not have any signs of dyspnea until they suffer an arrest. The treatment is directed at managing the underlying disorder and ventilating
12
the patient until the problem can be treated. Positive pressure ventilation will help improve oxygenation.
STROKE There are three major types of stroke. The ischemic stroke can be thrombotic or embolic in origin. A thrombotic stroke involves an in-situ clot in an artery that either supplies a part of the brain, such as the vertebral or carotid artery, or that is within the brain itself. An embolic stroke is similar but involves a clot that originated elsewhere in the body that traveled to the brain, occluding an artery within the brain itself. On the other hand, a hemorrhagic stroke involves a disruption of an artery of the brain itself, which bleeding into the brain. Ischemic strokes have both modifiable and nonmodifiable risk factors. The modifiable risk factors include hypertension, which is perhaps the most significant risk factor, cigarette smoking, diabetes, dyslipidemia, abdominal obesity, insulin resistance, sedentary lifestyle, alcoholism, poor dietary habits, psychological stress, such as depression, certain heart conditions, such as atrial fibrillation, myocardial infarction, and infective endocarditis, the use of cocaine or amphetamines, vasculitis, and hypercoagulability states. Nonmodifiable risk factors include advanced age, family history of stroke, and previous stroke. If an embolic stroke is anticipated, you will need to look for a possible source. The most common source is atrial fibrillation. In this case, the embolism comes from a fibrillating left atrium. Much less likely, an embolic stroke can come from a prosthetic heart valve, post-MI situation, rheumatic heart disease, bacterial endocarditis with vegetations, or a mechanical circulatory assist device, such as an LVAD. Long bone fractures can lead to fat emboli and compression sickness can lead to an air embolism. Lacunar infarcts are also ischemic strokes. These are small strokes that do not involve thrombosis but that involve degeneration of the small arteries that get replaced by collagen and lipids. The deep cortical structures are what are mostly involved in these types of strokes, with things like uncontrolled hypertension, diabetes, and old age being the most common underlying factors.
13
You also need to consider factors that impair systemic perfusion tha affect watershed areas where circulation is already compromised. These systemic conditions include hypotension, polycythemia, hypoxia, and severe anemia—each of which compromises the oxygenation of the body as a whole. Ischemia can less commonly be due to vasospasm of the cerebral arteries. It can happen after using cocaine or amphetamines, after a subarachnoid hemorrhage, or if there is venous sinus thrombosis for any reason, such as an intracranial infection or hypercoagulability disorder. There are many possible symptoms associated with an ischemic stroke, all of which involve some type of neurological dysfunction. Things to look out for include aphasia or dysarthria, facial droop, numbness on one side of the body, hemiparesis or hemiplegia, gait abnormalities, and visual disturbances. While embolic strokes happen in the daytime, thrombotic strokes more often happen during the night. Lacunar infarcts may have no or few symptoms but many of these can lead to multi-infarct dementia. The symptoms tend to have an acute or subacute onset, although there can be deterioration if there is cerebral edema, usually happening about 48 to 72 hours. Your diagnosis of ischemic stroke is primarily based on your clinical evaluation of the patient. Neuroimaging as soon as possible will differentiate between hemorrhagic and ischemic stroke. Bedside glucose testing is essential. Once the diagnosis is established, you will need to identify the underlying cause, particularly if an embolism is suggested. The MRI examination of the head will identify early ischemia better than a CT of the head. Evaluation of the cause of the stroke should include an ECG, possibly Holter monitoring to look for intermittent atrial fibrillation, troponin level, and an echocardiogram. A magnetic resonance or CT angiography can identify the vessels involved. Thrombotic disorders from things like hypercoagulability include obtaining coagulation studies, CBC, platelets, lipid profile, and fasting blood sugar. Rare causes that might need to be examined include those related to hypercoagulability, such as antiphospholipid antibodies or factor V Leiden disease. A urine drug screen for amphetamines or cocaine should be done.
14
In treating an ischemic stroke, you should know that some patients can be treated with some type of reperfusion therapy if less than 4.5 hours have passed since the stroke onset. All patients need antiplatelet therapy and those not candidates for thrombolysis can have anticoagulation therapy. Antihypertensive therapy is cautiously given because some degree of hypertension is necessary to maintain cerebral perfusion. Patients at certain stroke centers can be treated with angiographically directed thrombolysis with fewer systemic complications. Others can have a mechanical thrombectomy. Intracerebral hemorrhage is another form of stroke that comes from focal bleeding in the parenchyma of the brain. Almost all cases are associated with hypertension. Expect focal neurological deficits similar to ischemic strokes, with an increased chance of having seizures, headache, impairment of consciousness, and nausea. Hemorrhagic strokes, especially large ones, can be catastrophic. The most modifiable risk factor is hypertension, with others being cigarette smoking, poor dietary habits, obesity, and the use of stimulant drugs, such as cocaine or amphetamines. Things like arteriovenous malformations, congenital aneurysms, or other arterial malformations are less likely to be causative. Brain tumors, bleeding disorders, vasculitis, and excessive anticoagulation must also be considered. A sudden headache is a common presenting complaint as is loss of consciousness or seizures. The neurological deficits have a sudden onset and can be fatal within hours to days. Small hemorrhages have fewer symptoms besides minor headache and nausea. The only way to detect these strokes definitively is through neuroimaging, usually a noncontrast CT of the head. Figure 3 shows what an intracerebral hemorrhage looks like under CT scanning:
15
Figure 3.
Patients with a hemorrhagic stroke need to be treated supportively with moderate blood pressure reduction and possible surgical evacuation. Cerebellar hemorrhages are most prone to herniation so evacuation can be a life-saving measure.
16
STATUS EPILEPTICUS Status epilepticus is a neurological emergency with significant morbidity and mortality if not treated. Prolonged status epilepticus can lead to metabolic derangements, cardiac dysrhythmias, autonomic dysfunction, hyperthermia, rhabdomyolysis, pulmonary edema, aspiration, and permanent brain damage. There has been ongoing debate about the length of time necessary before a seizure can be called status epilepticus. It had been 30 minutes at one point but is now about five minutes. Another operative definition is the presence of two or more seizures without recovery of normal consciousness in between. More worrisome is refractive status epilepticus, which involves seizures lasting 60 minutes or more in spite of benzodiazepine or other anticonvulsant therapy. Malignant status epilepticus is the most severe aspect of this, with seizures despite general anesthesia, often seen in adults who have encephalitis. Ordinary cases of status epilepticus usually happen with preexisting epilepsy. Many will either have stopped taking their medications or will have low levels of anticonvulsive drugs in their system. CNS infections, including malaria, can cause status epilepticus. Less common causes are metabolic derangements, congenital brain diseases, anoxia, trauma, or drug/alcohol usage. There are two basic stages of status epilepticus. The first state involves tonic-clonic activity, hyperglycemia, increased blood flow, elevated body temperature, salivation, and sweating. After thirty minutes of this, regulatory processes break down and cerebral blood flow decreases. There is systemic hypotension and increased intracranial pressure. The tonic-clonic activity may actually diminish. There is cerebral hypoglycemia, hypoxia, acidosis, and metabolic disturbances, such as hyponatremia, hyperkalemia, and hypokalemia. Blood pressure and cardiac output drops. In treating the patient, manage their airway and start an IV. Give benzodiazepines or phenytoin to control seizures, thiamine, and glucose. The initial treatment of choice is IV lorazepam. The second-best treatment is IV fosphenytoin. Hypoglycemia must be urgently excluded and treated if present. Once the seizures have been controlled, blood
17
work and brain imaging are necessary unless the underlying cause of the status epilepticus is clear.
SYNCOPE Syncope involves the sudden but brief loss of consciousness and loss of muscle tone. Most patients spontaneously recover once they are recumbent but, until then you will see a weakness of the pulse, cool extremities, and shallow breaths with involuntary muscle jerking. This can be preceded by near-syncope, which is the sensation of an impending fainting episode. Seizures by themselves are not syncopal episodes. While most syncope comes out of inadequate blood flow to the brain, a few cases come from low substrate levels in the brain, such as insufficient oxygen or low glucose levels. Look first for situations of low cardiac output. These can come from systolic dysfunction, diastolic dysfunction, obstruction to cardiac outflow, poor venous return to the heart, or arrhythmias. These are collectively referred to as vasovagal syncope. Orthostatic hypotension comes when the normal mechanisms to increase blood to the brain, such as vasoconstriction or sinus tachycardia, do not happen when standing up. Evaluate syncope as soon as possible after the event. Find out the inciting events and if there were prodromal symptoms suggesting presyncope. Find out the duration of the syncopal episode. In a review of symptoms, look for evidence of occult bleeding, palpitations, chest pain, vomiting or diarrhea, and risk factors for pulmonary embolism. Determine if there have been prior similar events, known heart disease, or use of vasodilators, diuretics, or antiarrhythmic drugs. Your examination must include orthostatic blood pressure measurements. Listen for heart murmurs and note the patient’s mental status. Obtain an ECG. Check the stool for occult blood and get a neurological examination. Pulse oximetry, tilt table testing, or echocardiogram might be necessary. Rarely will CNS imaging be necessary. Things you should be most concerned about include multiple recurring instances of syncope, syncope during exertion, older age, new heart murmur, secondary injury from the episode, and a family history of sudden death.
18
The most benign causes of syncope include syncope brought on by fear or pain, orthostatic hypotension, prolonged standing, or seizure. Dangerous causes of syncope that should concern you include syncope with exertion, because this suggests cardiac outflow obstruction, syncope without warning, suggesting an arrhythmia, syncope while recumbent, which also suggests an arrhythmia, or syncope associated with significant injury.
LOSS OF CONSCIOUSNESS OR COMA A true coma is a level of unresponsiveness in which the patient cannot be awakened or aroused. This is an extreme form of impaired consciousness, in which there are varying degrees of mentation that do not represent full arousal or full coma. In order to have a coma, the disturbance must be in both cerebral hemispheres or must involve damage to the reticular activating system, which controls arousal. The reticular activating system is located in the pons, midbrain, and posterior diencephalon of the brain. Causes of coma can be focal ischemia of the reticular activating system, hemorrhage of the same area, hypoxia, hypoglycemia, drug overdose, or uremia. Increased intracranial pressure for any reason can lead to coma plus a secondary risk of brain herniation. Psychiatric causes can look like coma but can be relatively distinguished from a genuine coma by the neurological examination. Your examination should include an eye examination. The pupils can be mid-position and fixed, unequal, dilated, or pinpoint with a dysconjugate or paralyzed gaze. Examine the blink reflex as well as the oculocephalic reflex, which is the “doll’s eyes” examination, looking for movement in response to head rotation. Breathing and heart rate patterns can be abnormal. Cheyne-Stokes breathing, hypertension, and bradycardia can be present. The motor exam is variable, with completely flaccid muscles, muscle spasticity, myoclonus, decorticate posturing, or decerebrate posturing. Your diagnostic process includes a neurological examination, urgent imaging of the brain, pulse oximetry, blood glucose measurement, electrolytes, CBC, and a urine drug screen. If there is evidence of increased intracranial pressure, this may have to be
19
measured. If seizures are suspected, get an electroencephalogram. A lumbar puncture can look for a CNS infection. Other than a neurological examination, a general physical examination is warranted. Look for signs of trauma to the brain, such as contusions, skull fracture, rhinorrhea, and/or otorrhea. Hypothermia by itself can lead to coma and heatstroke can also lead to a coma. Petechiae or purpura along with systemic findings suggest CNS infection or sepsis. Needle marks can be seen with drug overdoses. Smell the breath for ketoacidosis or alcohol intoxication. The cardiac examination could suggest hypoperfusion of the brain. The Glasgow coma scale is a standardized way of determining the degree of coma, especially after a head trauma. Figure 4 shows the Glasgow coma scale:
Figure 4.
20
Motor findings can indicate the severity of the CNS process. The most severely affected patient will have complete flaccidity because the lower brainstem is not responding. Next severe is decerebrate posturing because only the lower brain stem centers are intact. The next most severely affected patient will have decorticate posturing, from cortical injury only. Other findings that are less severe are asterixis and multifocal clonus. As mentioned, the eye examination is important. Examine the fundi for evidence of papilledema, suggesting increased intracranial pressure. The oculocephalic reflex, if absent, suggests that the oculovestibular pathways are affected or that there is psychogenic unresponsiveness. A cold caloric test can also be done with cold water injected into the external ear. If the brainstem is normal, the eyes will deviate to the side of the irrigation. If the eyes do not move or if the gaze becomes dysconjugate, this is a less favorable prognosis because it means a deeper coma. Respiratory patterns are also important. Cheyne-Stokes breathing suggest bilateral hemisphere involvement. Hyperventilation is seen with dysfunction of the upper pons or midbrain. Gasping breathing with respiratory pauses mean a pontine or medullary injury, which leads to respiratory arrest. All comatose patients should have continuous pulse oximetry, bedside glucose measurement, and cardiac monitoring. A comprehensive metabolic panel and CBC, liver function test, and ammonia level should be draw. ABGs and carboxyhemoglobin level should be measured if carbon monoxide poisoning is suspected. Blood and urine testing for culture and toxicology should be done. ECG and chest x-ray may be indicated. The MRI exam or contrast CT scan will detect many intracranial lesions. Besides supportive measures, including treatment of hypotension, thiamin should be given intravenously if Wernicke encephalopathy is suspected. Naloxone is given if opioid overdose is suspected. Treat all underlying metabolic diseases. Control increased intracranial pressure with propofol sedation, benzodiazepines, hyperventilation, and mannitol as an osmotic diuretic. Corticosteroids are helpful if the problem is vasogenic brain edema.
21
in men only and is similar to finasteride. Spironolactone is used in women. Surgery to transplant follicles is done in some cases. Trichotillomania is treated with SSRIs and tinea capitis is treated with antifungal pills.
VITILIGO Vitiligo is an autoimmune loss of melanocytes in the skin with loss of skin pigmentation. It can be an autosomal dominant inherited disorder and antibodies exist to cells and tissues other than melanin in many cases. Figure 15 shows what vitiligo looks like:
Figure 15.
Most patients have no symptoms besides pigment loss, which mainly affects the distal extremities and face. It is cosmetically disfiguring, especially in dark-skinned persons. A Wood light examination can show slightly affected areas. The treatment of vitiligo is mainly supportive and involves wearing sunscreen because the depigmented areas are prone to sunburn. Calcipotriene and topical corticosteroids can be used to suppress the immune system and topical calcineurin inhibitors can be
92
world where hygiene is poor. Impetigo can be bullous or nonbullous. Bullous impetigo comes from staphylococcus, which releases a toxin that cause skin exfoliation. In nonbullous impetigo, there can be pustules or vesicles that can easily rupture. Figure 16 shows what impetigo often looks like:
Figure 16.
Ecthyma is simply a type of impetigo that has ulcerations that have thick crusts and surrounding reddened areas. Most impetigo can be treated with mupirocin, although there are other topical antibiotic treatments. Some patients, especially those with recurrences, will do better with oral antibiotics to eradicate the carrier status.
ACUTE OTITIS MEDIA Acute otitis media can be viral or bacterial and involve the middle ear cavity that has accumulated fluid from an upper respiratory infection and because of eustachian tube dysfunction that prevents drainage of the fluid. It is seen most commonly in infants and
94
To download the audio version of this course, please visit our website www.AudioLearn.com
502
