Question 6
A patient on your ward complains of feeling “unwell” while you are on call in the middle of the night. Vital signs are as follows: HR 120, BP 210/115 (baseline BP is 140/85), RR 18, SpO2 98% on room air, T 37.2 (oral).
- What is the definition of a “Hypertensive Emergency?”
The definition of Hypertensive Emergency includes:- Asymptomatic diastolic BP ≥ 130
- Hypertension with acute end organ damage:
- Hypertensive encephalopathy
- Acute aortic dissection
- Acute left ventricular failure
- Acute coronary syndrome
- Acute kidney injury
- Intracranial haemorrhage
- Acute ischemic stroke
- Preeclampsia/eclampsia (pregnancy after 20 weeks and up to six weeks postpartum).
A sudden change in blood pressure above SBP>180 and/or DBP>120, with or without symptoms, should warrant an investigation into end organ damage.
- What symptoms would you ask the patient about on history?
Symptoms to ask for on history:- Headache (intracranial haemorrhage)
- Visual disturbance (increased ICP)
- Chest pain (ACS, aortic dissection)
- Back pain (aortic dissection)
- Dyspnea (CHF, pulmonary edema)
- Assess for signs of seizure/altered level of consciousness/stroke (hypertensive encephalopathy)
- What would you look for on physical exam?
Physical exam includes:- Heart rate, respiratory rate, temperature, SpO2
- Blood pressure (both arms contemporaneously
- Neurological exam, LOC
- Fundoscopy – assess for exudates, retinal hemorrhages, papilledema
- Cardiac exam – new murmurs, S3, gallop
- Raised JVP
- Respiratory exam – crackles
- What investigations would you order at this time?
Investigations at this time include:- CBC with peripheral smear (evidence of hemolysis)
- Lytes, BUN, Creatinine
- Serum cortisol
- ECG
- CXR
- Urinalysis
The goal of therapy should be rapid reduction of blood pressure (MAP decrease ≤25%) with antihypertensives, by IV if necessary.
Resources:
- Hypertension Canada. Canadian Hypertension Education Program (CHEP) Recommendations. Retrieved from https://www.hypertension.ca/en/chep/
- Marik PE and Rivera R. Hypertensive emergencies: an update. Curr Opin Crit Care. 2011, 17:569-580.
- Vaughan CJ and Delanty N. Hypertensive emergencies. The Lancet. 2000, 356:411-417.
Question 7
What are the indications to treat hypertension?The indications to treat hypertension are:
- Hypertension emergency
- Asymptomatic diastolic BP ≥ 130
- Average documented SBP >140 and/or DBP >100 with clinical/laboratory evidence of end-organ damage
- Average documented SBP >160 and/or DBP > 100 with or without end-organ damage
What is the first line therapy for novel uncomplicated hypertension?
First line therapy for novel uncomplicated hypertension is a thiazide diuretic.
Beta blockers should be used in patients <60 years old.
ACE inhibitors, ARBs, or long-acting CCBs can be used as alternative first-line therapies if contraindications to the above exist (ACEi are relatively contraindicated in black patients).
The following are first-line therapies for hypertension in unique settings:
- ACS
- Hypertension with stable angina – Beta blocker or CCB
- Hypertension post-STEMI/NSTEMI – ACEi + Beta blocker, or ACEi
- CHF
- ACEi + Beta blocker
- Thiazide diuretic or loop diuretic for volume management
- Diabetes
- With cardiovascular and/or renal disease – ACEi + Beta blocker
- Without the above – ACEi
Patients admitted to hospital for other conditions (i.e. pneumonia, rheumatologic problems) may have isolated hypertension. In these cases, acute stress (i.e. pain, anxiety) can cause an isolated hypertension. To manage hypertension in these patients:
- Treat the underlying condition and any discomfort
- Monitor their blood pressure
- Follow-up with patient in clinic for BP monitoring after discharge
- Initiate anti-hypertensive treatment in hospital if evidence of a hypertensive crisis
Resource
Hypertension Canada. Canadian Hypertension Education Program (CHEP) Recommendations. Retrieved from https://www.hypertension.ca/en/chep/
Question 8
How do you define an acute COPD exacerbation?
Chronic obstructive pulmonary disease (COPD) is a respiratory condition characterized by progressive airway obstruction and lung hyperinflation.
Characteristic findings of COPD on pulmonary function tests (PFTs) include:
- FEV1/FVC <0.7
- FVC <0.8
- Post-bronchodilator FEV1 <80% of predicted
Acute COPD exacerbations can occur frequently, and are defined as a sudden worsening of dyspnea, cough and/or sputum production in the context of chronic COPD, necessitating an increase in the use of maintenance medications. COPD exacerbations are often precipitated by respiratory infections.
How would you manage an acute COPD exacerbation?
Management of an acute COPD exacerbation:
- Ventolin + Atrovent (β-agonist and anticholinergic)
- Prednisone 30-40mg PO daily for 5-14d
- Antibiotics:
- Simple exacerbations (dyspnea, increased sputum, purulence) – Amoxicillin, cephalosporins (2nd or 3rd generation), doxycycline, macrolides, septra
- Complex exacerbations (as above + FEV1<50%, or ≥4 or more exacerbations/year, or ischemic heart disease, or use of home oxygen, or chronic oral steroid use) – Fluoroquinolones, Clavulin
- Maintain Sp02 at 88-94% (BiPAP if required)
Resources
- MacIntyre N et al. Interpretative strategies for lung function tests. Eur Respir J. 2005, 26:948-968.
- O’Donnell et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease – 2008 update – highlights for primary care. Can Respir J. 2008, 15(Suppl A):1A-8A.
- Quon BS, Gan WQ and Sin DD. Contemporary Management of Acute Exacerbations of COPD: A Systemic Review and Metaanalysis. Chest. 2008, 133:756-766.
- Stanbrook MB. ACP Journal Club: review: antibiotics reduce treatment failure in acute chronic obstructive pulmonary disease exacerbations. Ann Intern Med. 2013, 158:JC5.
Question 9
You are called to the ward at night because of an acute onset of dyspnea. Outline your initial steps.
Initial steps in management include:
- History – onset, provoking/relieving factors, history of similar symptoms, associated symptoms (cough, sputum, hemoptysis, diaphoresis, nausea, vomiting, chest pain). Get PMHx and current inpatient care from patient chart
- Physical exam – vitals (HR, BP, RR, O2 sat, Temp), precordial exam, respiratory exam
- Investigations:
- CBC, Lytes, Cr
- ECG
- Troponin, CK
- Lactate (suspect sepsis or acute metabolic lactic acidosis)
- Venous or arterial blood gas (if suspect metabolic acidosis)
- CXR
- CT PE (if suspect PE)
- Supplemental O2
- Call for help:
- If ECG changes suggestive of Unstable Angina /NSTEMI/STEMI
- If Pulmonary embolism
- If unsure
Question 10
You are called to the ward at night because a patient is in distress and wants treatment for constipation.
- What options do you have to treat this?
Constipation in the hospital setting can occur for many reasons – pre-existing, medication/opiate-induced, low fibre diet, systemic disease (i.e. Parkinsonism), or even more acutely with ischemic gut. First step to managing constipation is identifying the underlying cause.Treatment options include:- Stool softener – docusate sodium (Colace)
- Osmotic agents – PEG, magnesium-citrate based products, sodium phosphate products, lactulose
- Stimulant laxitives – bisadocyl (dulcolax), glycerine suppository, senna
- Enemas – mineral oil, tap water, phosphate enema (fleet)
- Manual disimpaction
- What would be your first choice treatment in this case?
Treatment should start with PEG (time of onset 0.5-1hr, and evidence of greater efficacy than lactulose). Give no more than 250cc PEG the first time. A glycerine suppository can also be given to reduce irritation of hard or large stools.This patient should then be given a stimulant laxative (i.e. Senna) daily for constipation.The underlying cause should always be sought and treated.
Resource
Bharucha AE, Pemberton JH and Locke GR 3rd. American Gastroenterological Association technical review on constipation. Gastroenterology. 2013, 144:218-238.
