Course Modules - Common Emergencies

Cardiovascular Emergencies

Congestive Heart Failure

Heart failure is a condition in which the ventricles cannot pump forcefully enough to send blood out to meet the metabolic needs of the body. Certain conditions, such as narrowed arteries of the heart (coronary heart disease) or high blood pressure gradually degrade the heart’s functioning. It can involve the left side (ventricle) of the heart (Left-Sided Heart Failure), right side (ventricle) of the heart, or both. However, in general, congestive heart failure begins with the left ventricle, which is the heart’s main pumping chamber.

1. Left-sided Heart Failure: pulmonary circulation becomes congested, and fluid can back up into the lungs, causing shortness of breath. As the left side of the heart is ahead of the right side in circulation, it normally results in right-sided failure as well.
2. Right-sided Heart Failure: systemic circulation becomes congested, and fluid can back up into the abdomen, legs, and feet, causing swelling.
3. Systolic Heart Failure: the left ventricle fails to contract vigorously, indicating a pumping problem.
4. Diastolic Heart Failure: the left ventricle fails to relax or fill fully, indicating a filling problem.

Many conditions can contribute to heart failure. Many contributors are of modifiable lifestyle habits, such as diet, weight control, and vices:

1. Hypertension
2. Diabetes Mellitus
3. Congenital Heart Defects
4. Lifestyle: smoking, drinking
5. Obesity/Overweight
6. Valvular Heart Diseases

The nature of each type of heart failure changes their manifestations, as they affect different parts of the circulatory system. In congestion of both sides, both sets of manifestations can be found.

1. Right-sided Heart Failure: congestion of peripheral tissues results in edema (pedal, ascites), liver congestion (impaired liver function), and GIT congestion (anorexia, distress, weight loss).
2. Left-sided Heart Failure: congestion of pulmonic circulation results in pulmonary congestion (impaired gas exchange, pulmonary edema) which produce cyanosis, signs of hypoxia, coughing with frothy sputum, orthopnea, and paroxysmal nocturnal dyspnea. It also decreases cardiac output, which can product activity intolerance and signs of decreased tissue perfusion.

Classification

CHFs are commonly classified based on the NYHA Functional Classification or AHA/ACC Staging System.

Treatment modalities for patients with CHF include a reestablishment of normal oxygenation and circulation. This can be through pharmacologic, surgical, and nursing actions:

1. Oxygenation
2. Pharmacologic Intervention: inotropes (increases cardiac output), vasodilators, ACE inhibitors, diuretics (reduce fluid volume)
3. Surgical Intervention: pacemakers, mechanical heart pumps, or even heart transplants can be used if the heart of the patient is mechanically dysfunctional.
4. Nursing Management focuses on preventive practices. This may be done prior to, during, and after the diagnosis of congestive heart failure.
   • Maintenance of physical functioning: promotion of cardiac wellness
   • Adherence to treatment regimen
   • Weight monitoring to detect fluid retention from congestion, as well as a monitor for obesity and overweight correction
   • Diet and lifestyle modification: mainly limitations on sodium intake, as it is a major electrolyte directly related to fluid volume. Other lifestyle modifications such as smoking cessation and alcohol intake limitations have high value as preventive measures.
   • Rest Periods: the decreased cardiac output predisposes the patient to activity intolerance. When planning activities, adequate rest periods should be provided in order to manage physical and mental stress.
   • Blood Pressure Control: in addition to pharmacologic intervention, high blood pressure can be corrected with lifestyle and diet changes.

If unmanaged, congestive heart failure can result in kidney damage or even failure due to reduced blood flow to the kidneys, valvular problems from cardiac enlargement or extreme pressure, arrhythmias and dysrhythmias, and liver problems from fluid buildup, placing pressure on the liver.

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Gastrointestinal Emergencies

Gastrointestinal Bleeding

This is a symptom of an underlying disease which can result from a variety of diseases that occur in the esophagus, stomach, small intestine, or large intestine. Clotting disorders can also cause bleeding, such as in liver disease.

1. Etiology:
   • Peptic Ulcers
   • Neoplasms of the GIT
   • Esophageal Varices (portal hypertension)
   • Inflammation, e.g. from GERD, Ulcerative Colitis, Crohn’s Disease
2. Diagnostic Evaluation: endoscopy (EGD, Colonoscopy, Sigmoidoscopy), radiographic procedures (UGIS, Barium Enema)
3. Treatment:
   • Esophageal varices: vasopressin (Pitressin), balloon tamponade (Sengstaken-Blakemore, Minnesota Tubes)
   • Bleeding, in general: volume replacement (IVF, Blood) and gastric lavage (for evaluation of aspirate: amount of blood)

Pancreatitis

Also read: Pancreatitis (MS Lecture)

Inflammation of the pancreas, which can result in serious illness.

1. Clinical Manifestations:
   • Pain is often the first symptom, aggravated when lying down.
   • Turner’s (reddish-purple or greenish-brown discoloration on flank area) and Cullen’s (bluish discoloration around the navel) sign are evidences of necrotizing pancreatitis.
2. Treatment:
   • Pharmacologic: Demerol (meperidine), anticholinergics
   • Surgery may also be performed, but is normally contraindicated due to the acutely ill presentation of the patient.

Liver Failure

Hepatic failure is a condition in which the organ fails to fulfill its functions or is unable to meet the demands placed upon it.

1. Clinical Manifestations: jaundice, fetor hepaticus, motor dysfunction, changes in level of consciousness (hepatic encephalopathy)
2. Treatment: correct the cause of dysfunction or slow its progression. Supportive therapies are used.

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Metabolic Emergencies

The endocrine system regulates metabolic and tissue functions, growth and development, moods and emotions, and maintains homeostasis in response to stress.

Diabetes Mellitus

A disorder of the pancreas that causes alterations in glucose metabolism. It is a chronic condition in which the body is unable to metabolize glucose due to lack of effective insulin. It is an imbalance between insulin availability and need. Patients with DM can experience various complications:

1. Diabetic Ketoacidosis (DKA), among the most serious crises, occurs in uncontrolled hyperglycemia. Exacerbations can occur from illness, infection, alcohol, drug use, and other medical conditions that can increase glucose production or decrease insulin secretion.
   1. Clinical Manifestations:
      • Blood hyperosmolarity
      • Total body dehydration from polyuria as the body attempts to excrete glucose through urine.
      • Electrolyte imbalances
      • Ketoacidosis, ketonuria (hallmark)
      • Kussmaul’s respirations (deep, rapid breaths)
      • Fruity breath odor
   2. Diagnostic Evaluation: CBG, urinalysis, ABGs, BUN/Creatinine, serum electrolytes, serum osmolality (elevated), anion gap
   3. Treatment:
      • Correct acidosis, ketosis, glucose levels; and prevent complications.
      • Fluid (isotonic) and electrolyte replacement
2. Hyperglycemic Hyperosmolar Syndrome, another serious crisis, also occurs in hyperglycemia. It may be caused by withdrawal from oral hypoglycemic medication, TPN or tube feedings without sufficient water, or renal disorder treatments.
   1. Clinical Manifestations: those mentioned in DKA, except for ketoacidosis. HHS was formerly known as a hyperglycemic hyperosmolar nonketotic syndrome.
   2. Treatment: rapid fluid replacement to correct dehydration, glucose level correction

Syndrome of Inappropriate Antidiuretic Hormone

SIADH is an endocrine disorder of excessive ADH production, resulting in fluid retention through increased water reabsorption in the kidneys, resulting in hemodilution hyponatremia. If reversible, its cause is corrected.

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Renal Emergencies

Renal Failure

The inability of the kidneys to sufficiently filter waste from the blood. Many factors can affect kidney function. It can take two forms: acute or chronic

1. Acute Tubular Necrosis (Acute Renal Failure): renal injuries that are results of nephrotoxic and ischemic renal injuries. These may be prerenal (disorder of systems prior to filtration), intrarenal (disorder of the kidney itself), or postrenal (disorder of the urinary tract past the kidneys, causing waste to build up in the kidneys).
   • Staging:
     • Initial: hours to days— acute insult to signs of injury
     • Maintenance: one to two weeks— continued loss of glomerular filtration rate (GFR)
     • Recovery: months to years— restoration of GFR and tubular function.
   • Treatment: correction of the underlying cause. The patient is weighed daily to detect fluid imbalance.

Nephrotoxicity

Many drugs can become nephrotoxic with improper use. It should be normal practice to determine potential kidney damage, but it is especially important for patients with pathology of the kidneys. Consult with a nephrologist for any drugs being taken.

2. Chronic Renal Failure: gradual, progressive disorder of the kidneys characterized by an irreversible loss of renal function and reduction in GFR. It commonly occurs with DM and hypertension.
   • Treatment: dialysis with continuous renal replacement therapy (CRRT), intermittent hemodialysis, or continuous ambulatory peritoneal dialysis (CAPD), and renal transplant if necessary.

Stage	Description
Stage 1	Kidney damage— asymptomatic
Stage 2	Mild— rarely symptomatic
Stage 3	Moderate— clinical and laboratory signs
Stage 4	Severe— prominent signs
Stage 5	Kidney failure— uremic syndrome