The Washington Manual Internship Survival Guide (11 page)

Hypertensive Emergencies

•
  Encephalopathy

•
  Intracranial hemorrhage

•
  Unstable angina or MI

•
  Acute left ventricular failure with pulmonary edema

•
  Aortic dissection

•
  Eclampsia

•
  Renal insufficiency (new or worsened)

Hypertensive Urgencies

•
  Blood pressure >180/110

•
  Optic disc edema

•
  Severe perioperative hypertension

Things You Don’t Want to Miss (Call Your Resident)

Hypertensive emergencies:
hypertension with acute end-organ system damage.

Key History

•
  Check BP, pulse, respirations, O
₂
saturations, and temperature.

•
  Quickly look at the patient and review the chart. Get an ECG.

Focused Examination

•
  General: Is the patient distressed or ill-appearing?

•
  Vitals: Repeat BP yourself in both arms.

•
  HEENT: Check fundi for papilledema, retinal hemorrhages, or other hypertensive changes.

•
  Cardiovascular: Heart rate, JVP. Capillary refill.

•
  Lungs: Listen for crackles, breath sounds on both sides.

•
  Neurologic: Mentation, confusion, delirium, focal neurologic deficits.

Laboratory Data

Consider troponins, ECG, ABG, CBC, electrolytes, UA, and CXR.

Management

•
  
Treat the patient, not the BP reading. Acute lowering of BP in asymptomatic patients with long-standing hypertension can be dangerous.

•
  Permissive hypertension is usually advised by neurologists for patients with an acute ischemic stroke, unless the BP is severely elevated (>220/120) or conditions such as ACS, decompensated CHF, dissections, encephalopathy, ARF, and eclampsia coexist.

•
  Hypertensive emergencies require an ICU setting. The goal is to reduce the MAP by no more than 25% in the first 2 hours. IV hydralazine, nitroprusside, labetalol, esmolol, enalaprilat, and fenoldopam are often used. While arranging transfer to the ICU, certain wards allow medications to be started. Consider IV nitroglycerin for hypertension associated with MI or pulmonary edema. Nitroprusside and labetalol are useful in aortic dissection. Nitroprusside is also used for patients with
encephalopathy but often requires intra-arterial blood pressure monitoring.

•
  Hypertensive urgencies can usually be managed with oral medications with the goal of reducing BP over 24 to 48 hours. Examples include captopril 25 to 50 mg PO, clonidine 0.1 to 0.2 mg PO, or labetalol 200 to 400 mg PO. These can be repeated or titrated every 2 to 4 hours. Close follow-up is essential. PO/SL short-acting nifedipine should not be used in most medical patients.

COMMON ARRHYTHMIAS

•
  Obtain the vital signs, including temperature. Any chest pain or shortness of breath? What is the patient’s mental status?

•
  Review the telemetry and order a stat ECG.
Patients with chest pain, shortness of breath, altered mental status, or hypotension need to be seen immediately.

Major Causes of Rapid Heart Rate and Slow Heart Rates

•
  Rapid rates:

•  Regular: Sinus tachycardia, SVT, ventricular tachycardia, atrial flutter

•  Irregular: Atrial fibrillation with rapid ventricular rate (RVR), multifocal atrial tachycardia

•
  Slow rates:

•  Drugs (ß-blockers, CCB, digoxin)

•  Sick sinus syndrome

•  MI (especially inferior)

•  AV block

Things You Don’t Want to Miss (Call Your Resident)

•
  Ventricular tachycardia

•
  Unstable SVT

•
  Hypotension

•
  Angina or MI

Key History

•
  Check BP, pulse, respirations, O
₂
saturations, and temperature.

•
  Quickly look at the patient and review the chart, while waiting for a 12-lead ECG.

Focused Examination

•
  General: Does the patient look sick or distressed?

•
  Vitals: Repeat now.

•
  Cardiovascular: Heart rate, jugular venous pulse, skin temperature and color, capillary refill.

•
  Lungs: Listen for crackles and breath sounds on both sides.

•
  Neurologic: Evaluate for confusion or change in level of consciousness.

Laboratory Data

In addition to ECG, consider troponins, ABG, CBC, electrolytes, and CXR.

Management

•
  
Always complete the ABCs first and ensure O
₂
and IV access
. Place the patient on monitor or telemetry; consider transfer to a monitored bed on a cardiology floor.

•
  
If the patient is hypotensive and has atrial fibrillation with RVR, SVT, or ventricular tachycardia, emergency cardioversion may be required.

•
  First, call your resident. If the patient is unstable with serious signs or symptoms, a ventricular rate greater than 150, or both, you should prepare for immediate cardioversion. The patient may require sedation. Serious signs and symptoms per ACLS protocol include chest pain, shortness of breath, decreased level of consciousness, hypotension and shock, congestive heart failure, and acute MI. Refer to the proper ACLS algorithm at this point (see Chapter 3).

•
  
Atrial fibrillation with RVR but without evidence of hemodynamic compromise
can be rate controlled with diltiazem, metoprolol, esmolol, or digoxin. Amiodarone can also be considered, though there is a risk of pharmacologic cardioversion. Amiodarone is generally considered the best choice if heart failure and/or an accessory pathway is present.

•  
Diltiazem
, 0.25 mg/kg IVP over 2 minutes; if no response, repeat 0.35 mg/kg IVP over 2 minutes; follow with an IV infusion at 5 to 15 mg/h. Diltiazem is the agent of choice in most patients. Verapamil can also be used, 2.5 to 10 mg IVP, may repeat 5 to 10 mg IVP after 15 to 30 minutes for a maximum of 20 mg.

•  
Metoprolol
, 2.5 to 5 mg IVP over 2 minutes every 5 minutes to a total of 15 mg followed by oral dosing. Preferred agent if ischemia is suspected or present.

•  
Esmolol
, 0.5 mg/kg over 1 minute loading dose, followed by 50 μg/kg/min, maximum 300 μg/kg/min.

•  
Digoxin
, 0.25 to 0.5 mg IVP; then 0.125 to 0.25 mg IVP every 4 to 6 hours to a total dose of 0.75 to 1.35 mg; followed by oral dosing. Digoxin’s effect will take longer than other agents and is much less commonly used for acute rate control. It may, however, be used for this purpose for those with CHF.

•  
Amiodarone
, 150 mg IV over 10 minutes, followed by infusion of 1 mg/min for 6 hours, then 0.5 mg/min for 18 hours, is not FDA-approved for the treatment of atrial fibrillation, but studies have shown it to be effective. Its onset of action is slower than calcium channel blockers and b-blockers. Also, be cautious if atrial fibrillation has been present >48 hours as amiodarone can cause conversion to sinus rhythm and put the patient at risk for cardioembolic stroke.

•
  
SVT without evidence of hemodynamic compromise
can sometimes be broken with Valsalva maneuver, carotid sinus massage (one side at a time and always listen for bruits first), or both. If still in SVT, try
adenosine
, 6 mg rapid IV push, followed by 12 mg rapid IV push if necessary. Always remember to flush with at least 20 mL of NS after each IV push. If the complex width is narrow with stable BP, verapamil, 2.5 to 5 mg IV, or diltiazem, 10 mg IV, can be used. Adenosine should given with significant caution if WPW is suspected. If wide complex, manage as stable VT.

•
  For ventricular tachycardia, if pulseless or without BP, manage as ventricular fibrillation. If ventricular tachycardia with serious signs or symptoms, consider immediate synchronized cardioversion. If stable, follow the ACLS protocol (see Chapter 3).

FEVER

•
  What are the patient’s vital signs? What was the reason for admission? Is this a new finding? Any associated symptoms (e.g., cough, headache, change in mental status, and N/V)? Any antipyretics or current antibiotics? Any recent surgeries or procedures?

•
  Order CXR, blood and urine cultures.

•
  
Patients with symptoms concerning for meningitis or hypotension need to be seen immediately.

Major Causes of Fever

•
  Infections: Best to think of by site—lung, urine, IV sites, blood, CNS, abdomen, and pelvis. Confirm immune status.
Immunocompromised patients may warrant much more aggressive evaluation and empiric therapy
(e.g., post-chemotherapy neutropenic fever).

•
  Drug-induced fever: Antibiotics and many other drugs have been implicated.

•
  Postoperative atelectasis (though often invoked, there is minimal evidence to support this contention).

•
  Neoplasms.

•
  Rheumatologic diseases.

•
  Deep venous thrombosis/pulmonary embolism.

•
  Fever of unknown origin.

Things You Don’t Want To Miss (Call Your Resident)

•
  Meningitis

•
  Septic shock, particularly in neutropenic patients

•
  Endocarditis

Key History

•
  Check BP, pulse, respirations, O
₂
saturations, and temperature.

•
  Quickly look at the patient and review the chart.

Focused Examination

•
  General: Does the patient appear ill? Check all catheter sites (IV, central line, Foley, G-tube, etc.).

•
  Vitals: Repeat now. Tachycardia is an expected finding with fever. Recheck blood pressure.

•
  Cardiovascular: Heart rate, jugular venous pulse, skin temperature, and color. Any new murmurs? Capillary refill.

•
  Lungs: Listen for crackles and breath sounds on both sides.

•
  Abdomen: Assess for localized tenderness and bowel sounds.

•
  Extremities: Check calves for signs of deep venous thrombosis and joints for effusions.

•
  Neurologic: Mentation, photophobia, neck stiffness, Brudzinski’s or Kernig’s signs.

Laboratory Data

•
  Consider CBC, blood cultures (two sets at different sites; if a central line is present, be sure to get one peripheral set as well), CMP, UA and culture, sputum culture and Gram’s stain, CXR.

•
  LP if meningitis is suspected.

•
  Fluid collections (e.g., pleural effusion, ascites) may need to be tapped.

•
  Consider
Clostridium difficile
toxin stool testing.

Management

•
  Make sure the patient is hemodynamically stable. Review medications and obtain cultures. Give antipyretics (acetaminophen 650 mg PO/PR or ibuprofen 400 mg PO q6-8h prn). Ensure IV access and consider maintenance fluids for insensible losses.

•
  Consider antibiotics carefully.
If the patient is hemodynamically stable, immunocompetent, not toxic appearing, with no clear source of infection, it may be prudent to withhold antibiotics and await culture results.

•
  Patients with fever and hypotension require broad-spectrum antibiotics and IV fluids or pressors to manage the hypotension. Septic shock is an emergency (see above).

•
  Patients with fever and meningitis symptoms require antibiotics immediately. Do not wait for the LP to be completed. Start the antibiotics, then begin the LP.

•
  Consider changing or removing Foley catheters and any indwelling IV sites.

Febrile Neutropenia

•
  Patients with fever and neutropenia (<1000 cells/mm
³
) require a careful physical examination, with particular attention paid to mucosal surfaces, lungs, skin, and vascular access sites.

•
  Blood cultures for bacteria and fungi should be drawn; also consider urine culture, sputum culture, LP, and CXR if clinically indicated.

•
  Broad-spectrum antibiotics should be started.

•  Choices for initial therapy include fourth-generation cephalosporin, carbapenem or an antipseudomonal penicillin, with or without aminoglycoside.

•  If a catheter-related infection is suspected or the patient is known to be colonized with penicillin-resistant pneumococcus or methicillin-resistant
Staphylococcus aureus
, consider adding vancomycin to the above regimen.