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Differentiating Between Anxiety, Syncope & Anaphylaxis
Differentiating between anxiety, syncope & anaphylaxis Dr. Réka Gustafson Medical Health Officer Vancouver Coastal Health Introduction Anaphylaxis is a rare but much feared side-effect of vaccination. Most vaccine providers will never see a case of true anaphylaxis due to vaccination, but need to be prepared to diagnose and respond to this medical emergency. Since anaphylaxis is so rare, most of us rely on guidelines to assist us in assessment and response. Due to the highly variable presentation, and absence of clinical trials, guidelines are by necessity often vague and very conservative. Guidelines are no substitute for good clinical judgment. Anaphylaxis Guidelines • “Anaphylaxis is a potentially life-threatening IgE mediated allergic reaction” – How many people die or have died from anaphylaxis after immunization? Can we predict who is likely to die from anaphylaxis? • “Anaphylaxis is one of the rarer events reported in the post-marketing surveillance” – How rare? Will I or my colleagues ever see a case? • “Changes develop over several minutes” – What is “several”? 1, 2, 10, 20 minutes? • “Even when there are mild symptoms initially, there is a potential for progression to a severe and even irreversible outcome” – Do I park my clinical judgment at the door? What do I look for in my clinical assessment? • “Fatalities during anaphylaxis usually result from delayed administration of epinephrine and from severe cardiac and respiratory complications. “ – What is delayed? How much time do I have? What is anaphylaxis? •an acute, potentially -
CIRCULATORY COLLAPSE - EMERGENCY (ISS MED/3A - ALL/FIN) Page 1 of 2 Pages
SHOCK - CIRCULATORY COLLAPSE - EMERGENCY (ISS MED/3A - ALL/FIN) Page 1 of 2 pages NOTE The most critical step is identifying and treating the underlying cause. Basic causes of shock are: Anaphylaxis - severe allergic reaction Heart attack Loss of circulating blood volume (bleeding, burns, dehydration) Decompression sickness Venous dilation (allergy, pain, drugs, heat stroke, infection) High or low body temperature SIGNS Pulse - rapid, weak, thready Respiration - shallow, irregular, labored Blood Pressure - low, falling Mental State - confused, sluggish, anxious Eyes - pupils may be dilated Skin - cold, clammy, sweating If no pulse or respiration, perform {CARDIOPULMONARY RESUSCITATION: CPR - EMERGENCY} (SODF: ISS MED: EMERGENCY). 1. Evaluate vital signs and record every 5 minutes every 5 minutes. Time (minutes) 0 5 10 15 20 25 30 ALSP Blood Presssure (ALSP-4) Pulse Respiratory Rate ALSP Temperature (Assessment-4) ALSP Pulse Oximeter (Assessment-3) 2. Unstow and don Non-Sterile Gloves (ALSP Airway-4,5,6). If bleeding, control by applying direct pressure using Gauze Pads (Airway-11). 3. Prevent loss of body heat with clothing, sleeping bag, warm environment. 24 AUG 00 4044.shock.circ.collapse.em.doc SHOCK - CIRCULATORY COLLAPSE - EMERGENCY (ISS MED/3A - ALL/FIN) Page 2 of 2 pages 4. Attach ECG leads. Refer to {CARDIOPULMONARY RESUSCITATION: CPR - ECG DATA STORAGE - EMERGENCY} (SODF: ISS MED: EMERGENCY). 5. Contact Surgeon. 6. If no immediate ground communication available, start IV with 1L bag Normal Saline. Fully open roller clamp assembly to allow maximum flow. Refer to {INJECTIONS - NONPOWERED INTRAVENOUS FLUID INFUSION} (SODF: ISS MED: INJECTIONS/IV). 24 AUG 00 4044.shock.circ.collapse.em.doc. -
General Anesthesia for GI Endoscopy MP9519
Coverage of any medical intervention discussed in a WellFirst Health medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. General Anesthesia for GI Endoscopy MP9519 Covered Service: Yes Prior Authorization Required: No Additional An appropriate diagnosis code must appear on the claim. Information: Claims will deny in the absence of an appropriate diagnosis code. WellFirst Health Medical Policy: 1.0 Use of general anesthesia may be considered medically necessary for upper or lower gastrointestinal endoscopic procedures when there is documentation by the endoscopist or anesthesiology provider that ANY of these specific risk factors or significant medical conditions are present: 1.1 Prolonged or therapeutic endoscopy procedure is planned and requires deep sedation (e.g. endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), upper gastrointestinal stenting, emergency therapeutic procedures; OR 1.2 Anesthesia Risk Category III or greater based on ASA Physical Status Classification System* when there is increased risk for complication because of severe comorbidity; OR 1.3 Morbid obesity (BMI >40, or BMI >35) with comorbid medical conditions (refractory hypertension, obstructive sleep apnea, coronary heart disease, type 2 diabetes); OR 1.4 Inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment); OR 1.5 Spasticity or movement disorder complicating procedure (e.g. epilepsy, seizure disorder); OR 1.6 Persons with anticipated intolerance of standard sedative (e.g. previous problems with anesthesia or sedation, dependence on opiates, sedatives or hypnotics; or drug or alcohol abuse); OR 1.7 Patients who are pregnant; OR All WellFirst Health products and services are provided by subsidiaries of SSM Health Care Corporation, including, but not limited to, SSM Health Insurance Company and SSM Health Plan. -
Circulatory Collapse During Wound Closure In
Zhang et al. BMC Anesthesiology (2021) 21:4 https://doi.org/10.1186/s12871-020-01220-6 CASE REPORT Open Access Circulatory collapse during wound closure in spine surgery with an unknown cause: a possible adverse effect of topical application of vancomycin? Xiaoqing Zhang, Wenwen Zhai, Min Li and Xiangyang Guo* Abstract Background: Vancomycin (VCM) is effective in fighting Gram-positive bacteria related severe infections, and topical application of VCM powder is widely used in orthopedic surgery to prevent wound infection. However, VCM could lead to infusion rate-dependent antibody-and complement-independent anaphylaxis reaction by inducing direct release of histamine. Case presentation: We retrospectively analyzed seven cases of severe hypotension and shock during wound closure or immediately after orthopedic surgery with unidentifiable reasons. We found that these cases were all associated with local application of VCM powder during wound closure process. Two patients experienced sudden cardiac arrest. Most of the cases (6/7) with circulatory collapse were discharged without severe sequelae. While one case with application of 3 g VCM developed cardiac arrest and remained in a coma due to hypoxic-hypoxic encephalopathy. The clinical presentations and the time of the shock onset were considered to be related with a VCM induced anaphylaxis reaction. However, as this was a retrospective study, and there was no laboratory examination performed, the conclusion was made upon differential diagnosis based on clinical manifestations and the timing of the shock. Conclusions: Local application of VCM may not be as safe as was once believed and may lead to a related anaphylaxis. As VCM induced infusion-rate dependent, non-IgE mediated anaphylaxisischaracterizedbydelayed occurrence, severe hypotension and even circulatory collapse, surgeons and anesthesiologists should be extra vigilant during and after VCM application. -
Challenges in the Management of Acute Peptic Ulcer Bleeding
Review Challenges in the management of acute peptic ulcer bleeding James Y W Lau, Alan Barkun, Dai-ming Fan, Ernst J Kuipers, Yun-sheng Yang, Francis K L Chan Acute upper gastrointestinal bleeding is a common medical emergency worldwide, a major cause of which are bleeding Lancet 2013; 381: 2033–43 peptic ulcers. Endoscopic treatment and acid suppression with proton-pump inhibitors are cornerstones in the Institute of Digestive Diseases, management of the disease, and both treatments have been shown to reduce mortality. The role of emergency surgery The Chinese University of Hong continues to diminish. In specialised centres, radiological intervention is increasingly used in patients with severe and Kong, Hong Kong, China (Prof J Y W Lau MD, recurrent bleeding who do not respond to endoscopic treatment. Despite these advances, mortality from the disorder Prof F K L Chan MD); Division of has remained at around 10%. The disease often occurs in elderly patients with frequent comorbidities who use Gastroenterology, McGill antiplatelet agents, non-steroidal anti-infl ammatory drugs, and anticoagulants. The management of such patients, University and the McGill especially those at high cardiothrombotic risk who are on anticoagulants, is a challenge for clinicians. We summarise University Health Centre, Quebec, Canada the published scientifi c literature about the management of patients with bleeding peptic ulcers, identify directions for (Prof A Barkun MD); Institute of future clinical research, and suggest how mortality can be reduced. Digestive Diseases, Xijing Hospital, Fourth Military Introduction by how participants were sampled, their inclusion Medical University, Xian, China (Prof D Fan MD); Department of Acute upper gastrointestinal bleeding is characterised by criteria, and defi nitions of case ascertainment. -
Endoscopic Diagnosis and Management of Nonvariceal Upper
Guidelines Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021 Authors Ian M. Gralnek1, 2,AdrianJ.Stanley3, A. John Morris3, Marine Camus4,JamesLau5,AngelLanas6,StigB.Laursen7 , Franco Radaelli8, Ioannis S. Papanikolaou9, Tiago Cúrdia Gonçalves10,11,12,MarioDinis-Ribeiro13,14,HalimAwadie1 , Georg Braun15, Nicolette de Groot16, Marianne Udd17, Andres Sanchez-Yague18, 19,ZivNeeman2,20,JeaninE.van Hooft21 Institutions 17 Gastroenterological Surgery, University of Helsinki and 1 Institute of Gastroenterology and Hepatology, Emek Helsinki University Hospital, Helsinki, Finland Medical Center, Afula, Israel 18 Gastroenterology Unit, Hospital Costa del Sol, 2 Rappaport Faculty of Medicine, Technion-Israel Marbella, Spain Institute of Technology, Haifa, Israel 19 Gastroenterology Department, Vithas Xanit 3 Department of Gastroenterology, Glasgow Royal International Hospital, Benalmadena, Spain Infirmary, Glasgow, UK 20 Diagnostic Imaging and Nuclear Medicine Institute, 4 Sorbonne University, Endoscopic Unit, Saint Antoine Emek Medical Center, Afula, Israel Hospital Assistance Publique Hopitaux de Paris, Paris, 21 Department of Gastroenterology and Hepatology, France Leiden University Medical Center, Leiden, The 5 Department of Surgery, Prince of Wales Hospital, The Netherlands Chinese University of Hong Kong, Hong Kong SAR, China published online 10.2.2021 6 Digestive Disease Services, University Clinic Hospital, University of Zaragoza, IIS Aragón (CIBERehd), Spain Bibliography 7 Department of Gastroenterology, Odense University Endoscopy 2021; 53: 300–332 Hospital, Odense, Denmark DOI 10.1055/a-1369-5274 8 Department of Gastroenterology, Valduce Hospital, ISSN 0013-726X Como, Italy © 2021. European Society of Gastrointestinal Endoscopy 9 Hepatogastroenterology Unit, Second Department of All rights reserved. Internal Medicine – Propaedeutic, Medical School, This article ist published by Thieme. -
Defining and Measuring Quality in Endoscopy
Communication from the ASGE QUALITY INDICATORS FOR Quality Assurance in Endoscopy Committee GI ENDOSCOPIC PROCEDURES Defining and measuring quality in endoscopy Quality has been a key focus for gastroenterology, The expert panels that were convened in 2005 compiled a driven by a common desire to promote best practices list of quality indicators that were deemed, at the time, to be among gastroenterologists and to foster evidence-based both feasible to measure and associated with improved pa- care for our patients. The movement to define and then tient outcomes. Feasibility concerns precluded measures measure aspects of quality for endoscopy was sparked by that required data collection after the date of endoscopy ser- public demand arising from alarming reports about medi- vice. Accordingly, the majority of the initial indicators con- cal errors. Two landmark articles published in 2000 and sisted of process measures, often related to documentation 2001 led to a national imperative to address perceived of important parameters in the endoscopy note. The evi- areas of underperformance and variations in care across dence demonstrating a link between these indicators to many fields of medicine.1,2 Initial efforts to designate and improved outcomes was limited. In many instances, the require reporting a small number of basic outcome mea- 2005 task force relied on expert opinion. Setting perfor- sures were mandated by the Centers for Medicare & mance targets based on community benchmarks was intro- Medicaid Services, and the process to develop perfor- duced, yet there was significant uncertainty about standard mance measures for government reporting and “pay for levels of performance. Reports citing performance data often performance” programs was initiated. -
Impact of Intra-Aortic Balloon Support on Endothelial Function and Tissue Perfusion Markers in Severe Heart Failure
Central Journal of Cardiology & Clinical Research Bringing Excellence in Open Access Research Article *Corresponding author Silvia Gelás Lage, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Impact of Intra-Aortic Balloon Universidade de Sao Paulo, Sao Paulo, SP, Brazil, Av. Dr. Enéas de Carvalho Aguiar, 44, 05403-000 - São Support on Endothelial Paulo, SP, Brazil, Tel: (55-11) 26615302; Email: Submitted: 12 September 2018 Accepted: 03 October 2018 Function and Tissue Perfusion Published: 05 October 2018 Copyright Markers in Severe Heart © 2018 Lage et al. OPEN ACCESS Failure Keywords • Intra-aortic balloon pump; Severe heart failure; Antônio A. P. Fagundes Júnior, Liliane Kopel, Claudia Bernoche, Endothelial function; Central venous oxygen saturation; Arteriovenous carbon dioxide gradient; Milena F. Macatrão-Costa, Leonardo N. Lopes, Antonio P. B-type natriuretic peptide Mansur, and Silvia Gelás Lage* Heart Institute, Hospital das Clinicas HCFMUSP, Brazil Abstract Background: The intra-aortic balloon pump (IABP) is a common therapy available for ventricular support in critical cardiac patients. The aim of this study was to characterize the effect of IABP on endothelial function, on serum B-type natriuretic peptide (BNP) levels and on central venous oxygen saturation (ScVO2) and arteriovenous carbon dioxide gradient (∆PCO2) as perfusion tissue markers. Methods and results: Twenty-three patients with severe heart failure, mean age 50±13 years, left ventricular ejection fraction of 22±8% were included. All were on IABP support and the protocol considered 3 conditions: 1) IABP ratio 1:1, 2) IABP ratio 1:3 and 3) IAPB ratio 1:1. The period of time between conditions was 20 minutes. -
Shock and Circulatory Support
17 Emerg Med J: first published as 10.1136/emj.2003.012450 on 20 December 2004. Downloaded from REVIEW Critical care in the emergency department: shock and circulatory support C A Graham, T R J Parke ............................................................................................................................... Emerg Med J 2005;22:17–21. doi: 10.1136/emj.2003.012450 Effective resuscitation includes the rapid identification and will produce organ failure and, in the context of global hypoperfusion, multiple organ failure correction of an inadequate circulation. Shock is said to be ensues. The aim of resuscitation is to prevent present when systemic hypoperfusion results in severe shock worsening and to restore the circulation to dysfunction of the vital organs. The finding of normal a level that meets the body’s tissue oxygen requirements. haemodynamic parameters, for example blood pressure, Shock can arise through a variety of mechan- does not exclude shock in itself. This paper reviews the isms. Pump failure may be attributable to pathophysiology, resuscitation, and continuing inadequate preload (for example, severe bleed- ing), myocardial failure, or excessive afterload. management of the patient presenting with shock to the Shock can also occur with an adequate or emergency department. increased cardiac output as seen in distributive ........................................................................... shock (for example, septic or anaphylactic shock). Vital tissues remain ischaemic as much of the cardiac output -
Endoscopic Variceal Ligation: a to Z
Endoscopic Variceal Ligation: A to Z Division of Gastroenterology and Hepatology, Liver Clinic Department of Internal Medicine Soon Chun Hyang University School of Medicine, Soon Chun Hyang University Bucheon Hospital, Bucheon, Korea 김 상 균 Agenda 1. Endoscopic classification of esophageal varices 2. Endoscopic ultrasound for the management of esophageal varices 3. Endoscopic treatment of esophageal varices 1) Endoscopic injection sclerotherapy (EIS) vs. Endoscopic variceal ligation (EVL) 2) Primary prophylaxis for esophageal varices 3) Acute esophageal bleeding 4) Secondary prophylaxis after variceal bleeding 4. Procedure of endoscopic band ligation 5. Recurrence of esophageal varices after band ligation 6. Conclusions Case • 52/M, Chronic alcoholism • C/C : Abdominal distension, 1 month ago • MELD score:22, Child-Pugh class C with ascites • endoscopy What should be recorded? 1. F2, Lm, Cb, red wale marking, hematocystic spots 2. F3, Lm, Cb, RC (++), 3. F2, Lm, RC (++) 4. F3, RC (++) 5. F1, RC Endoscopic Classification According to Form F0: No varicose appearance F1: Straight, small-caliber varices F2: Moderately enlarged, beady varices F3: Markedly enlarged, nodular or tumor-shaped varices The Japanese Research Society for Portal Hypertension. Dig Endosc 2010;22:1-229 Endoscopic Classification According to Color • Cw: White varices Cb: Blue varices • Cw-Th: Thrombosed white varices • Cb-Th: Thrombosed blue varices Endoscopic Classification According to Location • Ls: Locus superior • Lm: Locus medialis • Li: Locus inferior • Lg-c: Adjacent to the cardiac orifice • Lg-cf: Extension from the cardiac orifice to the fornix • Lg-f: Isolated in the fornix • Lg-b: Located in the gastric body • Lg-a: Located in the gastric antrum Modified from Sohendra N, et al. -
Postinduction Paced Pulseless Electrical Activity in a Patient with a History of Oropharyngeal Instrumentation– Induced Reflex Circulatory Collapse
CASE REPORT Ochsner Journal 16:315–320, 2016 Ó Academic Division of Ochsner Clinic Foundation Postinduction Paced Pulseless Electrical Activity in a Patient With a History of Oropharyngeal Instrumentation– Induced Reflex Circulatory Collapse Ryan J. Kline, MD,1 Ky Pham, MD,1 Carmen L. Labrie-Brown, MD,1 Ken Mancuso, MD,1 Paul LeLorier, MD,2 James Riopelle, MD,1 Alan David Kaye, MD, PhD1 1Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA 2Department of Internal Medicine, Louisiana State University Health Sciences Center, New Orleans, LA Background: Reflex hypotension and bradycardia have been reported to occur following administration of several drugs associated with administration of anesthesia and also following a variety of procedural stimuli. Case Report: A 54-year-old postmenopausal female with a history of asystole associated with sedated upper gastrointestinal endoscopy and post–anesthetic-induction tracheal intubation received advanced cardiac resuscitation after insertion of a temporary transvenous pacemaker failed to prevent pulseless electrical activity. The patient’s condition stabilized, and she underwent successful cataract extraction, intraocular lens implantation, and pars plana vitrectomy. Conclusion: Cardiac pacemaker insertion prior to performance of a procedure historically associated with reflex circulatory collapse can be expected to protect a patient from bradycardia but not necessarily hypotension. Keywords: Anesthesia–general, heart arrest, pacemaker–artificial, shock Address correspondence to Alan David Kaye, MD, PhD, Professor and Chairman, Department of Anesthesiology, Louisiana State University Health Sciences Center, 1542 Tulane Ave., Room 656, New Orleans, LA 70112. Tel: (504) 568-2319. Email: [email protected] INTRODUCTION during 2 upper gastrointestinal (GI) endoscopic examina- Reflex hypotension and bradycardia have been reported tions under IV sedation without topical anesthesia. -
UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood
British Society of Gastroenterology UUKK CCoommppaarraattiivvee AAuuddiitt ooff UUppppeerr GGaassttrrooiinntteessttiinnaall BBlleeeeddiinngg aanndd tthhee UUssee ooff BBlloooodd DDeecceemmbbeerr 2 2000077 St. Elsewhere's Hospital National Comparative Audit of Blood Transfusion TABLE OF CONTENTS Acknowledgements Executive summary 4 Introduction 9 Why is this audit necessary? 9 Aims 9 What does this audit want to report? 10 What does this report include? 10 Who are the principal stakeholders? 10 Methods How were NHS trusts recruited? 11 Nature and size of the case sample for this audit 11 Pilot 11 Audit standards and criteria 11 Data collection 12 Audit report 12 How to read this report 13 The 1993/4 audit of acute upper gastrointestinal haemorrhage 14 Initial results of the UK audit of UGI bleeding and the use of blood 2007 15 Section 1 Principal Findings 17 Section 2 Organisational of Care 21 Section 3 Presentation and Initial care 27 Section 4 Patient Descriptors 33 Section 5 Endoscopy 35 Section 6 Additional Medical Management 43 Section 7 Surgery and Radiology 45 Section 8 Blood Transfusion 48 Section 9 Outcomes 52 Recommendations 54 Action Points 55 Discussion 56 Conclusions 58 References 59 Appendices 1 Participating hospitals i 2 Audit standards vii 3 Rockall score calculator xi 4 Audit questionnaires xii St. Elsewhere s Hospital 2 Acknowledgements We wish to thank all those who have participated in the UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood. We recognise that this audit required an enormous amount of time and effort from many staff in each participating hospital, and are extremely grateful to everyone who took part for providing what we hope will be useful, meaningful data both at local and national level.