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Manejo paciente con vih en urgencias medicas

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MANEJO DEL PACIENTE AGUDAMENTE ENFERMO EN URGENCIAS. ABORDAJE.
oct 2014

Publié dans : Formation
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Manejo paciente con vih en urgencias medicas

  1. 1. ENFOQUE Y MANEJO EN URGENCIAS (ESE HUS) DE UN PACIENTE VIH POSITIVO. Agustín Vega Vera. MD. Profesor Universitario.
  2. 2. Equipo de trabajo
  3. 3. Equipo de trabajo
  4. 4. ¿qué ha pasado? • Urgencias • VENCER: • El estigma asociado al VIH/SIDA • MEJORAR • Bioseguridad (Menos accidentes equipo de salud)
  5. 5. ¿qué ha pasado en urgencias ESE HUS? SINDROME DE CONSUNCIÓN.
  6. 6. ¿qué ha pasado en urgencias ESE HUS? SINDROME DE CONSUNCIÓN.
  7. 7. ¿qué ha pasado en urgencias ESE HUS? SINDROME DE CONSUNCIÓN. VALORACIÓN GRUPO SOPORTE NUTRICIONAL
  8. 8. DISFUNCIÓN SNC. 30% (38 ptes)
  9. 9. DISFUNCIÓN SNC. 30% (38 ptes) Zona hipodensa/mal definida/edema/efecto masa ligero Temporal, parietal, subcortical occipital. Probabilidad origen isquémico, vasculitis de origen viral.
  10. 10. DISFUNCIÓN SNC. 30% (38 ptes) Zona hipodensa/mal definida/edema/efecto masa oblitera ventriculo Temporal, parietal, subcortical occipital. Probabilidad toxoplasmosis cerebral.
  11. 11. DISFUNCIÓN SNC. 30% (38 ptes) Absceso cerebral.
  12. 12. DISFUNCIÓN SNC. 30% (38 ptes) Lesión hiperdensa cerebral.
  13. 13. DISFUNCIÓN SNC. 30% (38 ptes) MIELITIS TRANSVERSA
  14. 14. DISFUNCIÓN SNC. 30% (38 ptes) MENINGITIS TUBERCULOSA. BK + Agradecimiento. Dra Martha Jácome. Laboratorio ESE HUS.
  15. 15. DISFUNCIÓN SNC. Meningitis linfocitaria. MENINGITIS TB VS VIRAL VS CRIPTOCOCO.
  16. 16. DISFUNCIÓN SNC. Meningitis linfocitaria. MENINGITIS TB VS VIRAL VS CRIPTOCOCO.
  17. 17. DISFUNCIÓN SNC. Meningitis linfocitaria. MENINGITIS TB VS NEUROLUES.
  18. 18. DISFUNCIÓN SNC. Parálisis facial bilateral.
  19. 19. DISFUNCIÓN SNC. Parálisis facial bilateral. En rehabilitación
  20. 20. Meningitis por criptococosis. “El turbante”
  21. 21. DISFUNCIÓN SNC. 30% (38 ptes) ¿qué hacer?. Medicina interna. (responsable) TAC cerebral vs RNM cer gadolinio. Técnica flair. 4,5Tesla. Si no contraindicación. Punción lumbar. Cultivos: gérmenes comunes, micobacterias, hongos. NO olvidar ADA. Tinta china. Inicio Trimetropim Sulfa (15 mg/kg) IV. Si masa cerebral. Anticonvulsivante (Difenil hidantoina vs A. valproico (TARAE)). Corticoides. Dexametasona. Interconsultas: Rehabilitación. Neurología. Neurocirugía. Infectología. Psiquiatría de enlace. Manejo Delirio. Toxoplasmosis. Tuberculosis. Criptococo.
  22. 22. Compromiso respiratorio. 57 (44%) ptes. Tuberculosis 28 / 57 total. 50%
  23. 23. Compromiso respiratorio. 57 (44%) ptes.
  24. 24. Compromiso respiratorio. 57 (44%) ptes.
  25. 25. Compromiso respiratorio. 57 (44%) ptes.
  26. 26. Compromiso respiratorio. 57 (44%) ptes. Paciente VIH + Cárcel TOS Expectoración Dolor pleurítico derecho
  27. 27. Compromiso respiratorio. 57 (44%) ptes. Paciente VIH + Cárcel TOS Expectoración Dolor pleurítico derecho
  28. 28. Compromiso respiratorio. 57 (44%) ptes. Paciente VIH + TOS Expectoración BK +
  29. 29. Compromiso respiratorio. 57 (44%) ptes. Taxista Sintomático Respiratorio BK +++
  30. 30. Compromiso respiratorio. 57 (44%) ptes.
  31. 31. Compromiso respiratorio. 57 (44%) ptes. Manejo como TB miliar.
  32. 32. Compromiso respiratorio. 57 (44%) ptes. Neumonía por CMV. “ojos de buho”
  33. 33. Compromiso respiratorio. 57 ptes. ¿Qué hacer? 1. Aislamiento respiratorio. Mascarilla. N95. 2. Trimetropim sulfa. 15 mg/kg. IV. 3. Penicilina cristalina. Ceftriaxona y/o claritromicina. (Doxiciclina). 4. Laboratorio. LDH. Elevada. (>1000). Gases arteriales. Hipoxemia refractarias. PAFi. 5. Rx tórax. TACAR. 6. ESPUTO: BAAR y cultivo micobacterias. Gram-KOH. 7. IC Neumología. LBA. 8. Valorar necesidad / prioridad UCIA. 9. Valoración infectología.
  34. 34. Compromiso respiratorio. ¿Qué hacer? 1. Aislamiento respiratorio. Mascarilla. N95. Detecta 93% Descarta 97% Cain KP, McCarthy KD, Heilig CM, Monkongdee P, et al. An algorithm for tuberculosis screening and diagnosis in people with HIV. N Engl J Med. 2010 Feb 25;362(8):707-16.
  35. 35. ¿Qué hacer? 1. Aislamiento respiratorio. Mascarilla. N95. Compromiso respiratorio. Bk + Cultivo micobacterias + 87% Siga Buscando Monkongdee P, McCarthy KD, Cain KP, et al. Yield of acid-fast smear and mycobacterial culture for tuberculosis diagnosis in people with human immunodeficiency virus. Am J Respir Crit Care Med. 2009 Nov 1;180 (9):800-1.
  36. 36. Compromiso hematológico. 24/127 (18.9%)
  37. 37. Compromiso hematológico. 24/127 (18.9%) PANCITOPENIA
  38. 38. Compromiso hematológico. 24/127 ¿qué hacer? 1. No transfundir. Excepto vida en peligro de muerte. 2. Valoración inmediata de hematología. 3. Realizar AMO (patología oportunista) + biopsia 4. Cultivos gérmenes comunes + micobacterias. 5. Valoración anemia. 6. Tratamiento suplencia: hierro vs eritropoyetina. 7. Aislamiento de contacto. Neutropenia. 8. Valoración Infectología.
  39. 39. CASOS EXCEPCIONALES • Pacientes VIH positivos.
  40. 40. CASOS EXCEPCIONALES
  41. 41. GAS EN LOS TEJIDOS
  42. 42. Fascitis necrosante.
  43. 43. Necrosis avascular del fémur.
  44. 44. Espondilodiscitis
  45. 45. Pioderma Gangrenoso.
  46. 46. Lesión hipoecoica de característica solidas. Compromiso esclera, crecimiento exofìtico, infiltra cámara anterior.
  47. 47. Abdomen agudo.
  48. 48. EVENTOS ADVERSOS MEDICAMENTOS
  49. 49. EVENTOS ADVERSOS MEDICAMENTOS
  50. 50. Kaposi-
  51. 51. Lipodistrofia.
  52. 52. GRACIAS!!!!

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