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Office Urgencies
Gil C. Grimes, MDApril 2006
Competing Interests This take is funded by an
unrestricted free time grant from my wife.
First Thoughts Office emergency???
Call 911
Not an interesting lecture
Second Thoughts Nurse calls in sick Billing computer crashes Personality disorder family scheduled for 11 arrives
at 8 EHR displays only Cyrillic Text Four unmedicated ADHD children in waiting area 141 pre-authorization requests on the morning fax 35 Medication refill list on double book patient Handling the 2 inch internet search on the
interaction between Fibromyalgia and chronic yeast infection
Final Outline Hypertensive crisis Asthma Exacerbation Hypoglycemia Syncope Febrile Seizure Epistaxis
Hypertensive Crisis Hypertensive Urgency if 180/100 Hypertensive Emergency if end-organ
damage Stroke, heart failure and hypertensive
encephalopathy commonest example of end-organ damage
Cerebral Infarction 16-32% Acute pulmonary edema 14-30% Hypertensive encephalopathy 9.6-24% Acute CHF 7.4-20% Acute MI or unstable angina 5.9-18% Intracranial bleeding 0.7-8.6% Aortic dissection 0-4.4%
Hypertension 1996;27(1):144-147 Level 2c
Hypertensive Crisis Causes
Essential hypertension 54-86% Renovascular 0-21% Neurogenic 0-16% Diabetic Nephropathy 0-21% Pheochromocytoma 0-10% Primary Hyperaldosteronism 0.46-
0.75%BMJ 1983;286:19-21 Level 4NEJM 1979;301(23):1273-1276 Level 4
Hypertensive Crisis Investigations
Urinalysis with microscopy Dymsorphic red cells Pigmented granular casts Absence of blood or protein make glomerular disease less
likely1
Complete blood count Electrolyte, urea, creatinine, glucose
Low potassium think hyperaldosteronism 2
EKG Signs of strain LVH
CXR Signs of heart failure
Doppler US to look for renal artery stenosis 3
1- Am J Kidney Disease 1992;20(6):618-628 Level 2b2- NEJM 1979;301(23):1273-1276 Level 43- Ann Intern med 2001;135:401-411 Level 2a
Hypertensive Crisis Goal blood pressure control
Evidence of end organ damage immediate reduction of pressure 1
No end organ damage, reduce over 24 hours
Reduce BP but keep MAP >70 mm HG (prevents cerebral hypoxia) or greater than 20 mm Hg with frequent readings 2
1- Arch Intern Med 1997;157:2413-2446 Level 52- BMJ 1973;1:507-510 Level 4
Hypertensive Crisis Drugs of Choice
Sodium Nitroprusside (clonodine, nifedipine, nicardipine or fenoldopam alternative)
NNT 2 for clonodine vs. nifedipine Labetalol in patients without heart block or
pulmonary disease Nitroglycerine for ischemia or angina Phentolamine if catecholamine related
hypertension Esmolol for aortic dissection Hydralazine for pregnancy if pre-eclamptic
Arch Int Med 1989;149:260-265 Level 1b
Hypertensive Crisis Mortality is high
40% patient dead within 3 years 1 Mainly renal failure or stroke
Admit to hospital ICU if end organ damage
1- J Hypertension 1995;13:9150924 Level 2b
Asthma Exacerbation Prevalence 1
3.7% persons of all ages had attacks 1999
Male 3.3% Females 4.4% Caucasian 3.7% African Americans
4.6% High rate of severe asthma
exacerbations in pregnant women with moderate to severe asthma 2
1- National Health Interview Survey 19992- Ob Gyn 2005;106(5):1046-54 Level 2b
Asthma Exacerbation Triggers
Allergens, house dust, molds, grass pollens, cedar 1
Air pollutants such as ozone, sulfur dioxide, cigarette smoke 2-4
Respiratory tract infections RSV, parainfluenza, rhinovirus common
offenders 5 Atypical bacteria
1- BMJ 2002;324:763 Level 3b2- Thorax 2005;60(10):814-21 Level 3b3- Lancet 2003;361(9373):1939-44 Level 2b4- JAMA 2003;290(14):1859-67 Level 2b5- Pediatr Asthma Allergy Immunol 2002; 15:69 Level 2b
Asthma Exacerbation Medication triggers
Eye drops (timolol etc) 1
Glucosamine-chondroitin 2
Aspirin some non-selective beta-blockers 3
1- Cortland Forum 1996;9(2):83,96-114 Level 52- DynaMed Asthma Exacerbation access March 2006 Level 53- J Am Board Fam Pract 2002;15(6):481-484 Level 4 Level\\\
Asthma Exacerbation History
Ask and establish about precipitating factors Generally worse in the afternoon Past therapy
Steroids Hospitalization Intubation What has worked
Descriptors of dyspnea Out of air, need to take a deep breath, tight throat,
voice tight, scared, agitated Descriptors differ by race
Chest 2000;117(4):935-43 Level 2b
Asthma Exacerbation Investigations
Peak expiratory flow <100 l/min prior to therapy <300 l/min after therapy Consider admission 1
Pulse Oximetry <92% marker for resp failure LR+ 4.2 2
1- Ann Emerg Med 1982;11:64-69 Level 42- Thorax 1995;50:186-188 Level 4
Asthma Exacerbation Therapy
Oxygen 40-60% titrate with pulse oximetry Beta-2 agonists via MDI with spacer or
nebulizer 3 doses MDI 20 minutes apart (shorter duration of
treatment) Continuous better than intermittent nebulizer 1
Ipratropium reduces likelihood of admission in children (NNT 10) 1
Steroids (40 mg prednisolone) within one hour to reduce admissions (NNT 6) 1
No additional benefit oral vs. IV Inhaled steroids not as much data
1- Cochrane Library 2001 Issue 1:CD002178 Level 1a
Asthma Exacerbation Additional measures Out of office to hospital
Mag Sulfate Evidence on IV form only after failing other therapy 1 Lots of data disease oriented, very conflicting
outcomes May be more effective inhaled as neb 2
Antibiotics have an unclear role (trial data lousy)
Consider watching or contacting patient 4 hours later (as beta effect wanes)
1- Cochrane Library 2001 Issue 1:CD002178 Level 1a2- Cochrane Library 2005 Issue 4:CD003898 Level 1a
Hypoglycemia Consider in patients with reduced level
of consciousness (7%) 1
Biggest risk is diabetes aggravated by- 2
Missed meals 25-52% Alcohol consumption 22-48% Insulin overdose 15-20% Exercise 6-14% Unidentified causes 19-24% Medications 4%
1- J Emerg Med 1992;10:679-682 Level 1b2- Arch Emerg Med 1989;6:183-188 Level 2b
Hypoglycemia Treatment (based on Level of consciousness)
Oral sugar if conscious Glucagon IV or IM if semiconscious Give long-acting carbohydrate as follow up
Inquire about the following for prevention Insulin regimen Duration of diabetes Glycemic control Prior episodes Current medications and new medications Herbals
SyncopeCauses
Arrhythmias Aortic Stenosis Myocardial Infarction Aortic dissection Pulmonary Embolism Seizure TIA Subclavian Steal
Carotid Sinus Hypersensitivity
Vasovagal Orthostasis Drugs Situational Syncope
(Micturation or defecation)
Psychogenic Hypoglycemia
Syncope Symptoms
Palpitations…arrhythmia Chest pain…ischemia, PE, aortic stenosis Nausea…vasovagal, bradyarrythmia Diaphoresis...MI, vasovagal syncope Pallor…Vasovagal syncope Hunger palpitations, sweating,
anxiety….hypoglycemia Multiple nonspecific associated complaints…
psychogenic
Syncope Prodrome to
vasovagal Pallor Nausea Headache Sweating Faintness Palpitations Flush
Warning period typically present up to 5 minutes prior
Assuming supine position may abort episode
Observer may note cold hands, pale skin, tachycardia
Syncope Body Position Most episodes do not occur when
supine When first standing…orthostasis When sitting or
recumbent...arrythmia, hypoglycemia, seizure, psychiatric
Syncope Preceding Events
Psychological stress…vasovagal Preceded by exertion…cardiac causes Micturation
Can occur at beginning during or end Young men otherwise healthy likely related
to valsalva mechanism Older men and women orthostasis, drugs,
age Older men with BPH predispose to valsalva
Syncope Seizure activity
Activity after syncope is often present form multiple causes
Single tonic convulsion most common postsyncopal seizure
Clonic movements may occur usually brief Incontinence common with hypoglycemia
Best discriminating features for seizure 1
Orientation immediately after event (5x more likely if pt disoriented)
Age <45 (3x more likely) Nausea or sweating prodromal reduce likelihood
of seizure1- J Neurol 1991;238(1):39 Level 2b
Syncope Investigations
ECG with rhythm strip diagnostic in 11% cases 1
Especially if no obvious cause Older patient Palpitations
Labs may be useful in selected cases CBC…rule out anemia Lytes, BUN, Creatinine, Glucose, Magnesium
Calcium may identify metabolic disorders ABG….hypoxia or hypercarbia Tox screen Cardiac Enzymes if preceding chest pain
1- NEJM 1983;309(4):197-204 Level 2c
Syncope Investigations
Tilt table testing Recurrent syncope Single syncopal episode in high risk patient
with no evidence of structural CV disease Part of evaluation of exercise-induced
syncope Not indicated
Single syncopal episode without injury Clear-cut vasovagal features
American College of Cardiology 1996 Level 3
Syncope Investigations
Carotid sinus massage All patients >60 with unexplained
syncope Syncope with shaving, turning heads,
wearing tight collars Prerequisite
IV access Absence of bruits Atropine available ECG and BP monitoring
Syncope Investigations
Technique Apply pressure over each sinus for up to
5 seconds Patient is supine position
Interpretation Abnormal asystole >3 seconds Vasodepressor response Systolic BP
drops >50 mmHg no bradycardia
JAMA 1992;268(18):2553
Syncope Simple
Algorithm First Stage
H&P 12 lead EKG with
rhythm strip Hemoglobin &
glucose DX in 42%
Second Stage Echocardiogram Carotid sinus
massage Tilt testing EEG Brain imaging or
Carotid Doppler Selected EP
Studies Dx in 41 %
Eur Heart J 2000;21(11):935-40 Level 1b
Febrile Seizures Simple (most common)
Brief (15 minutes or less) Generalized tonic-clonic activity No focal component Normal neurological and physical
exam Resolves spontaneously
Febrile Seizures Complex (less common)
>15 minutes Partial or focal onset >1 seizure in 24 hours Consider CNS infection
Febrile Seizures Prevalence
2-5% in US and Europe 5-10% India 8.8% Japan 14% Guam
Age 6 months to 3 year peak 18 months 6-15 % occur after 4 Rare after 6 year
Arch Dis Child 2004;89(8):751 Level 4
Febrile Seizures Viruses frequently implicated
Human Herpesvirus 6 in 26% patients 1
Enteroviruses 2 15-19% Influenza virus 3 19-20% Parainfluenza 12% Adenovirus 9%
1- J Pediatr 1995;127(1):95 Level 32- J Infect Dis 1997 ;175(3)700 Level 33- Pediatrics 2001;108(4):e63 Level 3
Febrile Seizures Risk Factors
DTP (whole cell) 5.7x risk day of vaccination 1
6-9 cases per 100K MMR 2.83x risk 8-14 days 1
25-34 cases per 100K Absolute risk 1.56 per 1,000 2
Causation unclear No long-term Sequela
1- NEJM 2001;3459):656 Level 1b2- JAMA 2004;292(3):351 Level 1b
Febrile Seizures History
Look for features of complex febrile seizure
Peak temperature <102 F tend to be complex febrile seizures
If seizure occurs >1 day after onset of fever consider complex seizure
Physical Exam Nuchal rigidity, Brudzinski sign, Kernig’s
sign not sensitive or specific
Febrile Seizure Investigation
Electrolytes, Glucose, Calcium, Urinalysis Lumbar puncture and blood culture if
clinically indicated 1
Hx of irritability, decreased feeding, lethargy AMS post-ictal Meningismus signs Complex seizure features Pretreatment with antibiotics
2-5% incidence of meningitis 2
1- Ann Emerg Med 2003;41(2):215 Level 42- Arch Dis Child 2004;89(8):751 Level 4
Febrile Seizure EEG
Best predictor of recurrence 54% had recurrence abnormal EEG 25% had recurrence with normal EEG
Timing in question (better to wait 2 weeks) Neuroimaging
Indicated if focal seizure or partial Delayed resolution or prolonged seizure Prolonged pos-ictal mental status changes
Neurology 2000;56:616 Level 1a
Febrile Seizure Recurrence
1/3 will recur 1
50% in 1st year 90% in 2nd year
Increased if younger 50% recurrence if <1
Decreased risk if temperature >104
1- Arch Dis Child 2004;89(8):751 Level 5
Febrile Seizure Risk for future non-febrile seizures
FHx of epilepsy Preexisting neurologic deficits Preexisting delayed development Atypical febrile seizures 2-4% will have 1 unprovoked seizure
Risk 4-5x of general population
NEJM 1987;316(9):493 Level 2b
Febrile Seizures Treatment 1
No medications unless prolonged seizure Diazepam or midazolam effective
Prevention Systematic review of acetaminophen no
difference 2 Ibuprofen not effective a preventing
seizures 3
1- BMJ 200;321(7253):83 Level 1b2- Cochrane Librar 2002Issue 2:CD003676 Level 1a3- Pediatrics 1998;102(5):e51 Level 1b
Epistaxis 90-95% anterior 5-10% posterior Fracture associated anterior
ethmoidal artery
Am Fam Physician 2005;71:305
Epistaxis Causes
Trauma Rubbing, picking Foreign body
Substance abuse Cocaine Tobacco
Local Infection Nasal Polyps Neoplasm
Medications Steroids Aspirin, Plavix etc.
Systemic disease HTN Hemophilia Leukemia Liver disease Platelet
dysfunction Thrombocytopenia
Epistaxis Risk Factors
Posterior nosebleed 48% hypertensive 37% prior epistaxis
Follow circadian patterns Peak in morning Smaller peak evening
BMJ 2004;321:112 Level 2b
Epistaxis Management
Go with what is common Anterior nasal compression Use of decongestant soaked cotton
helps Tilt head forward
Reduces pharyngeal pooling Decreases nausea and vomiting
Am Fam Physician 2005;71:305 Level 5
Epistaxis Management Anterior
If simple measures do not work consider…….
Suction clots Anesthetize nose with cotton pledget 1%
tetracaine 1-3 minutes (slows blood flow) Use of sympathetic agent helps Cautery
Silver nitrate (preferred) Electrocautery risk possible perforation
Epistaxis
Epistaxis Management Posterior
Consider hospitalization Pack nasopharynx