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