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Office Urgencies Gil C. Grimes, MD April 2006. Competing Interests This take is funded by an unrestricted free time grant from my wife.

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Presentation on theme: "Office Urgencies Gil C. Grimes, MD April 2006. Competing Interests This take is funded by an unrestricted free time grant from my wife."— Presentation transcript:

1 Office Urgencies Gil C. Grimes, MD April 2006

2 Competing Interests This take is funded by an unrestricted free time grant from my wife.

3 First Thoughts Office emergency??? Call 911 Not an interesting lecture

4 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

5 Final Outline Hypertensive crisis Asthma Exacerbation Hypoglycemia Syncope Febrile Seizure Epistaxis

6 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 % Acute CHF % Acute MI or unstable angina % Intracranial bleeding % Aortic dissection 0-4.4% Hypertension 1996;27(1): Level 2c

7 Hypertensive Crisis Causes Essential hypertension 54-86% Renovascular 0-21% Neurogenic 0-16% Diabetic Nephropathy 0-21% Pheochromocytoma 0-10% Primary Hyperaldosteronism % BMJ 1983;286:19-21 Level 4 NEJM 1979;301(23): Level 4

8 Hypertensive Crisis Investigations Urinalysis with microscopy Dymsorphic red cells Pigmented granular casts Absence of blood or protein make glomerular disease less likely 1 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): Level 2b 2- NEJM 1979;301(23): Level 4 3- Ann Intern med 2001;135: Level 2a

9 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: Level 5 2- BMJ 1973;1: Level 4

10 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: Level 1b

11 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: Level 2b


13 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 Ob Gyn 2005;106(5): Level 2b

14 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): Level 3b 3- Lancet 2003;361(9373): Level 2b 4- JAMA 2003;290(14): Level 2b 5- Pediatr Asthma Allergy Immunol 2002; 15:69 Level 2b

15 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, Level 5 2- DynaMed Asthma Exacerbation access March 2006 Level 5 3- J Am Board Fam Pract 2002;15(6): Level 4 Level\\\

16 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): Level 2b

17 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 Ann Emerg Med 1982;11:64-69 Level 4 2- Thorax 1995;50: Level 4

18 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:CD Level 1a

19 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:CD Level 1a 2- Cochrane Library 2005 Issue 4:CD Level 1a


21 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: Level 1b 2- Arch Emerg Med 1989;6: Level 2b

22 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


24 Syncope Causes 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

25 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

26 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

27 Syncope Body Position Most episodes do not occur when supine When first standing…orthostasis When sitting or recumbent...arrythmia, hypoglycemia, seizure, psychiatric

28 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

29 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

30 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): Level 2c

31 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

32 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

33 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

34 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): Level 1b


36 Febrile Seizures Simple (most common) Brief (15 minutes or less) Generalized tonic-clonic activity No focal component Normal neurological and physical exam Resolves spontaneously

37 Febrile Seizures Complex (less common) >15 minutes Partial or focal onset >1 seizure in 24 hours Consider CNS infection

38 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

39 Febrile Seizures Viruses frequently implicated Human Herpesvirus 6 in 26% patients 1 Enteroviruses % Influenza virus % 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

40 Febrile Seizures Risk Factors DTP (whole cell) 5.7x risk day of vaccination cases per 100K MMR 2.83x risk 8-14 days 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

41 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, Kernigs sign not sensitive or specific

42 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

43 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

44 Febrile Seizure Recurrence 1/3 will recur 1 50% in 1 st year 90% in 2 nd year Increased if younger 50% recurrence if <1 Decreased risk if temperature > Arch Dis Child 2004;89(8):751 Level 5

45 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

46 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:CD Level 1a 3- Pediatrics 1998;102(5):e51 Level 1b


48 Epistaxis 90-95% anterior 5-10% posterior Fracture associated anterior ethmoidal artery Am Fam Physician 2005;71:305

49 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

50 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

51 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

52 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

53 Epistaxis

54 Management Posterior Consider hospitalization Pack nasopharynx


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