Anaphylaxis
อาการและอาการแสดงตั้งแต่ 2 ระบบขึ้นไป
– Skin : flushing, urticaria, angioedema– CV : tachycardia, hypotension, syncope, arrhythmia
– GI : nausea, vomiting, diarrhea, abdominal distension
– Respiratory : rhinorrhea, laryngeal edema, wheezing, asphyxia, pulmonary edema
– Neuro : loss of consciousness, headache, disorientation
Anaphylaxis (treatment)
ABC, iv, O2, monitor
Epinephrine
– 0.3-0.5 ml (0.01ml/kg in children) of epinephrine 1:1000
– Maintain blood pressure
– Inhibit mediator release by Increasing intracellular cAMP
– bronchodilatation
Antihistamine ( 48 hours)
– H1 blocker : diphenhydramine, chlorpheniramine
– H2 blocker : cimetidine, ranitidine
Corticosteroid
Inhaled beta agonist
Vasopressor : for hypotension not response to iv fluid
– Dopamine
– Levophed
Status epilepticus
Continuous seizure >= 30 mins
>=2 seizures without full recovery of consciousness
Morbidity : hypoxia, hyperthermia, circulatory collapse, neuronal injury
Secondary cause
Drug intoxication
Eclampsia
Intracranial pathology
Metabolic: hypoglycemia, hyponatremia
CNS infection
Status epilepticus (treatment)
ABC, iv, O2, monitor
DTX ( thiamine+glucose)
Anticonvulsant
– Diazepam 5 mg iv every 5 mins, upto 20 mg
– Dilantin 20 mg/kg iv at 50 mg/min
– Additional dilantin 5-10 mg/kg iv
– Phenobarb 20 mg/kg iv, additional 5-10 mg/kg
– General anesthesia ( midazolam, propofal, thiopental)
Supportive care
– Cooling, foley’s catheter
Diabetic coma
Hyperglycemic crisis
– Diabetic ketoacidosis (DKA)
– Hyperosmolar hyperglycemic state (HHS) or Hyperosmolar hyperglycemic nonketotic coma (HHNC)
Hypoglycemic coma
Diabetic ketoacidosis (DKA)Pathogenesis
Insulin deficiency
Counterregulatory hormone excess ( glucagon, cathecolamine, cortisol, growth hormone)
– Hyperglycemia
– High serum osmolarity
– Loss of water and electrolyte due to glucosuria ( osmotic diuresis)
– Ketosis and metabolic acidosis due to lipolysis, fatty acid oxidation, ketoacid formationDiabetic ketoacidosis (DKA)Precipitating factor
Error in insulin used
Stress events
– Infection, stroke, MI, trauma, pregnancy, hyperthyroidism, pancreatitis, pulmonary embolism, surgery, steroid use
25% no clear causes
Diabetic ketoacidosis (DKA) Clinical presentation
Hyperglycemia : polyuria, polydipsia
Volume depletion : tachycardia, hypotension
Acidosis : kussmaul respiration
Abdominal pain, vomiting
Mental status change, coma
Diabetic ketoacidosis (DKA) Diagnosis
Blood glucose > 250 mg/dl
Acidosis :
– arterial pH <7.3
– serum bicarbonate <15
Ketonuria and increased serum ketone
Diabetic ketoacidosis (DKA) Differential diagnosis
High anion gap metabolic acidosis
– Methanol
– Uremia
– DKA/ AKA
– Paraldehyde
– Iron/ INH
– Lactic acid
– Ethylene glycol
– Salicylate
Diabetic ketoacidosis (DKA) Treatment
Volume repletion
Reversal of metabolic consequence
Correct electrolyte and acid-base imbalance
Treat precipitating causes
Avoid complication
Fluid
0.9%NSS 1000-1500 ml in 1st hour
500-1000 ml/hr in 2nd-3rd hour
250 ml/hr in 4th-8th hour
125 ml/hr later
Insulin
RI 10 U (0.15U/kg) iv bolus, then 0.1 U/kg/hr iv infusion
Blood glucose should decrease 75-100 mg/dl/hr
Patassium
K initially may increased ( acidosis, hemoconcentration)
K will decrease rapidly after treatment of DKA
Every patients should get K supplement unless K >5.5
Don’t give RI if K <3.5
Bicarbonate
If pH<7ไม่มีความเห็น