Docstoc

Office Urgencies

Document Sample
Office Urgencies Powered By Docstoc
					Office Urgencies

       Gil C. Grimes, MD
           April 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 4
NEJM 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 2b
2- NEJM 1979;301(23):1273-1276 Level 4
3- 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 5
2- 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 1999
2- 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 3b
2- Thorax 2005;60(10):814-21 Level 3b
3- Lancet 2003;361(9373):1939-44 Level 2b
4- JAMA 2003;290(14):1859-67 Level 2b
5- 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 5
2- DynaMed Asthma Exacerbation access March 2006 Level 5
3- 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 4
2- 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 1a
2- 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 1b
2- 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
Syncope
Causes
     Arrhythmias                Carotid Sinus
     Aortic Stenosis             Hypersensitivity
     Myocardial Infarction      Vasovagal
     Aortic dissection          Orthostasis
     Pulmonary Embolism         Drugs
     Seizure                    Situational Syncope
                                  (Micturation or
     TIA                         defecation)
     Subclavian Steal           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           Warning period
    vasovagal              typically present up
       Pallor             to 5 minutes prior
       Nausea            Assuming supine
       Headache           position may abort
       Sweating           episode
       Faintness         Observer may note
       Palpitations       cold hands, pale
       Flush              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
                      seizure
1- 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                  Second Stage
                   First Stage                      Echocardiogram
                          H&P                       Carotid sinus
                                                      massage
                          12 lead EKG with
                           rhythm strip              Tilt testing
                          Hemoglobin &              EEG
                           glucose                   Brain imaging or
                          DX in 42%                  Carotid Doppler
                                                     Selected EP
                                                      Studies
Eur Heart J 2000;21(11):935-40 Level 1b
                                                     Dx in 41 %
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 3
2- J Infect Dis 1997 ;175(3)700 Level 3
3- 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 1b
2- 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 4
2- 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 1b
2- Cochrane Librar 2002Issue 2:CD003676 Level 1a
3- 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                         Medications
       Trauma                          Steroids
            Rubbing, picking           Aspirin, Plavix etc.
            Foreign body          Systemic disease
       Substance abuse                 HTN
            Cocaine                    Hemophilia
            Tobacco                    Leukemia
       Local Infection                 Liver disease
       Nasal Polyps                    Platelet dysfunction
       Neoplasm                        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

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:5
posted:2/1/2013
language:Unknown
pages:55