2.7.19 Conference Summary

EM/IM Conference: Hypertension

Asymptomatic Hypertension - Dr. Linda Katirji

ACEP Clinical Policy:

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  • No reason to screen patients for end organ damage if they are presenting with asymptomatic HTN as their only complaint.

    • Only caveat: If they have poor follow-up, checking a renal panel is reasonable

  • They are more likely to have a more poorly controlled blood pressure at one month, otherwise no increase in MACE or other cardiac events

    • Levy et al (2008)

      • No benefit to the patient when we lower the blood pressure

      • Similar return visits to the ED in 24 hours and 30 days

      • No increase in death

    • Should ED docs initiate long term antihypertensives?

      • Maybe- consider in patients without close follow up but always refer to a primary care physician


Hypertensive Urgency - Dr. Mirela Dobre, nephrology


HTN Emergencies:

  • Severe elevation of BP >180/120 mmHg associated with evidence of new or worsening target organ damage

    • Really at any BP with severe symptoms and target organ damage

  • If untreated: 1 year death rate >79%

  • True HTN emergency- place on drip, admit to ICU

 Hypertensive Urgencies:

  • Severe BP elevation in stable patients without acute or impeding change in target organ damage or dysfunction

  • No need to refer to ED, immediate reduction in the ED, or hospitalization

  • Why do we worry about blood pressure?

    • Need to treat elevated blood pressure long term because it significantly reduces mortality, ischemic stroke

    • Start a dual therapy on people with a BP above 180

    • Make sure they have follow-up- need blood pressure rechecks in one month

      • Don’t drop BP too fast because it ruins renal pressure

    •  Correct Measurement of BP: relaxed, sitting, feet on floor, back supported >5 min, no stimulation, 30 min prior, empty bladder, no talking, cuff applied against skin

      • Have patients buy a blood pressure cuff- check as outpatient

  •  Causes of HTN urgency: Medication noncompliance, lifestyle factors, access to health care, health literacy, white coat HTN, pain

 For ED docs: What meds to start?

  • Primary agents that reduce clinical events: thiazide diuretics, ACEi/ARB, CCB. If you start a second agent, choose one from different class with complementary activity

  • Calcium channel blocker is the safest bet to start with (once a day, cost effective)


Airway Grand Rounds: The Anatomical Difficult Airway - Dr. Matt Stull

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  • Indications for airway

    • Failure to oxygenate

    • Failure to ventilate

    • Failure to protect airway

    • Anticipated clinical course (shock, procedure, facilitate evaluation)

  • Predictors of RSI difficulty

    • Look

    • Evaluate - 3-3-3 rule (mouth opening - tip of mentum to hyoid bone - thyromental distance)

    • Mallampati (see below)

    • Obstruction

    • Neck mobility

https://www.clinicaladvisor.com/the-waiting-room/mallampati-score-anesthesia-obstructive-sleep-apnea/article/471394/

https://www.clinicaladvisor.com/the-waiting-room/mallampati-score-anesthesia-obstructive-sleep-apnea/article/471394/

  • Difficult airway algorithm

  • Predictors of difficulty ventilating (MOANS)

    • Mask seal (trauma, beard, blood, deformity)

    • Obstruction/obesity

    • Age >55

    • No teeth

    • Stiffness (lung resistance)

  • BVM troubleshooting

    • Use two-handed thenar technique rather than CE

    • Consider use nasopharyngeal airway (avoid oral airway… can cause bleeding, vomit, etc)

    • Use PEEP valve (need to give time to exhale)

  • Predictors of extra-glottic device (EGD) difficulty (RODS)

    • Restricted mouth opening

    • Obstryction

    • Distorted airway

    • Stiffness (lung resistance)

  • Difficult airway algorithm

    • Call for assistance if needed and available

    • Have multiple back up plans

    • Paralytics are usually your friend (just be thoughtful when using)

    • Take one best attempt

      • Direct laryngoscopy

      • Standard geometry video laryngoscopy

      • Hyperangulated video laryngoscopy (D-blade) - look in their mouth, don’t look at the camera until blade and tube are in the mouth

  • “Awake look”

    • Sedation + topical anesthesia

    • Choice of technique (DL vs. VL/D-blade vs fiberoptic)

      • Glottis visualized

        • If static physiology —> RSI

        • Dynamic pathology —> “awake intubation”

      • Glottis not visualized

        • EGD

        • Fiberoptic

        • Cricothyrotomy





Hand Infections: Dr. Yasmin Moftkhar

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Exam: inspection, palpation, range of motion

  • Flexor profundus tendon: Place hand against bedsdie and flex DIP

  • Flexor supplundus: Hold other hands still, flex entire finger

  • Neurovascularly intact:

    • Vascular: radial pulse + capillary refill

    • Neuro: Radial, median, ulnar nerve

    • Two point discrimination

Infections:

  • Cellulitis: oral antibiotics

    • Make sure there is not tenderness to palpation of deep structures- this would be a signs of a deeper infection

  • Felon: subcutaneous infection of the pulp space of the distal finger or thumb

    • most commonly staph aureus

    • most have associated cellulitis that needs oral antibiotics

    • It’s an abscess: Drain it

  • Animal Bites:

    • Clean copiously and irrigate, explore wound, heal by secondary intention

    • Rx- augmentin x3-7 days, give tetanus, consider rabies.

  • Closed fist injuries (ie fight bite): x-ray to look for fracture/foreign bodies

    • Typically Eikenella

    • Treatment: Augmentin: prophylaxis 3-5 days, established infection: 5-14 days.

      • Hand surgeon if deeper infection.

  • Herpetic Whitlow: burning pruritic lesion with vesicular bullae

    • Cause: HSV 1+2

    • Treatment: Usually resolves in 1-3 weeks without treatment.

  • High Pressure Injections: Progress quickly to ischemia.

    • Get x-rays, start broad spectrum antibiotics, give tetanus

    • Do Not: Do a ring block, apply tourniquet, use solvent, remove fluid, use ice

  • Flexor tenosynovitis: Infection of flexor tendons and sheath

    • Kanavel Signs: finger held in flexion, fusiform swelling, tenderness along flexor sheath, pain with passive extension of finger

    • Ultrasound: Look for fluid in sheath, always consider a water bath

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Acetaminophen Overdose- Dr. Leyya Suleman-Civis

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Remember, Tylenol is in everything. Most people do not read labels before taking medications.

Case: 22 yo F presents altered after nausea, vomiting. History of depression, no other known history. Mildly tachycardic. AST/ALT both in the 1000s

  • Differential for significant transaminitis: shock liver, other toxins, hepatitis, trauma, Reye’s syndrome, lab error

  •  Accurate Tylenol Dosing: Max 4g/day in an adult. 650 mg q4 hours, 975 mg q6 hours but better q8 hours

    • Max 80 mg/kg per day in child

Acetaminophen Toxicity Basic Facts:

  • Acute ingestion: >7.5g in adult, >150 mg/kg is concerning, >250 mg/kg is most likely toxic

  • Chronic ingestion: >6 grams per 24 hours for 2 or more days, >150 mg/kg for more than 24 hours

  • Peak concentration at 30 minutes to 2 hours, half life 2.5 hours

  • Hepatic injury occurs within 12 hours of excessive exposure

  • Risk factors for hepatotoxicity: low glutathione stores (alcoholics, immunodeficient, malnutrition), increased p450 activity (AEDs, TB meds), meds that complete with glucuronidation pathway (bactrim, opiates), age >40, smoking, accidental overdose (usually supratherapeutic dosing)

Stages of Toxicity:

  • Stage 1: in first 24 hours, nonspecific symptoms like n/v, malaise, anorexia +/- hypokalemia, metabolic acidosis

  • Stage 2: 24-72 hours: hepatotoxicity, nephrotoxicity, can recover

  • Stage 3: 72-96 hours: some develop fulminant hepatic failure (AST/ALT >10,000, hypoglycemia, ARF, 28% risk of death)

  • Stage 4: 4 days -2 weeks: recovery if you made it through stage 3

Treatment of overdose:

  • Rumack Matthew line- only 1% risk of hepatotoxicity below line, based on 4 hour post-ingestion level

  • Treatment: Consider activated charcoal less than 4 hours from ingestion

  • N-acetylcysteine is mainstay of treatment: Prevents NAPQI binding, replenishes hepatic glutathione stores

  • NAC is 100% in preventing hepatotoxicity within 8 hours of ingestion

  • Oral: 140 mg/kg loading dose than 70 mg/kg every 4 hours for 17 doses total

  • IV 150 mg/kg over 15-60 minutes, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours (20 hours total)

Leah Carter