PECARN Pediatric Head Injury/Trauma Algorithm

Presenter: Dr. Tara Kopp, Pediatric EM

• SNOUT – sensitivity = rule out
• SPIN – specificity = rule in
• PECARN = cohort of 20+ large academic institutions that combine to produce academic research studies
• ciTBI = clinically important traumatic brain injury
• Want to have high sensitivity = screening test = rule out ciTBI and need for CT scan

PECARN Criteria:

• Age: <2 yo or >2 yo
• GCS ≤14 or signs of basilar skull fracture or signs of AMS
  • AMS = Agitation, somnolence, repetitive questioning, or slow response to verbal communication
• History of LOC or history of vomiting or severe headache or severe mechanism of injury
  • Small children = severe fall > 3 ft
  • Older children = severe fall > 5ft

Observation vs CT scan

• Observation usually 4-6 hours; may take into account time from injury
• Children with no PECARN criteria ciTBI predictors = lots of head CTs which could be avoided
• Recommend repeat physical exam prior to discharge if observation

Conclusion:

• Severe injury mechanism
  • Children with isolated severe injury mechanism are at low risk of ciTBI, and many do not require imaging.
• Scalp hematoma
  • Clinicians should use patient age, scalp hematoma location and size, and injury mechanism to determine need for imaging in otherwise asymptomatic children.
• VP shunt
  • Children with VP shunts had higher CT use but similar rates of ciTBI compared with children w/o VP shunts. (limited sample size)

Peritonsillar abscess

Presenter: Dr. Brett Nelson

• Most common deep space infection of head and neck
• Predisposed by previous/recurrent tonsilitis or pharyngitis

Symptoms:

• Odynophagia, drooling, voice change

Evaluation:

• Edematous tonsil, pillars, or soft palate
• Uvula deviation
• Ultrasound
  • Intraoral US with endocavitary probe
  • Submandibular US with linear probe
• CT head/neck w/ contrast

Treatment:

• Needle aspiration – start near superior tonsillar pole, cut needle guard to protect
• Incision and drainage – cut scalpel guard to protect
• Antibiotics alone – Augmentin +/- Clindamycin
• “Quinsy Tonsillectomy” – performed by ENT in severe cases of airway obstruction

Disposition: Usually discharge with ENT follow-up

Sialolithiasis and Suppurative Parotitis

Presenter: Dr. Kyle Stucker

Sialolithiasis:

• Calcium carbonate or phosphate stones of salivary gland in stagnant duct
• Mechanism: Duct stasis, bacterial migrations alter salivary gland pH, altered duct electrolyte concentrations
• 80% occur in submandibular gland
• Usually 5mm; >10-15 mm = “megalith”

Diagnosis:

• Facial swelling, pain, discomfort
• Clinical – stone may be palpated
• CT scan
• Ultrasound

Treatment:

• <5 mm stone
  • Conservative
  • Outpatient therapy and analgesia
  • Gland massage
  • Sialogogues, such as lemon drops
  • Antibiotics if concern for infection
  • ENT referral
• > 5mm
  • Consider ENT consult

Suppurative Parotitis

• Duct infection or infected stone
• Evaluated with CT or US
• Collect cultures if visible purulent discharge

Treatment:

• Augmentin or clindamycin if penicillin allergy
• Admit for IV abx (Unasyn) if concern for sepsis, signs of trismus or airway compromise

Small Group Lecture: ENT Foreign Bodies

Present: Dr. Taylor Strohmaier

Ear foreign body:

• Lidocaine, mineral oil, hydrogen peroxide – anesthesia and kill insect

Removal techniques:

• Irrigation – may utilize IV catheter; contraindicated in TM perforation and button battery
• Forceps – flat or alligator, right angle tool, currette (lighted if available)
• Dermabond + Q-tip – allow glue to become tacky
• Snake pediatric NG tube/foley past to attempt to drag out

Consider otic drops if TM perforation or significant EAC trauma

• Cipro-dex drops
• Dry ear precautions

Consult ENT:

• Unable to remove FB
• Patient requires sedation

Eye foreign body:

Eye exam: EOM, pupils, visual acuity, fluorescein stain, Woods lamp, slit-lamp exam, tonometry, ultrasound, CT scan (may be helpful if concern for metallic FB)

Removal techniques: irrigation, moist Q-tip or cotton swab, 18 g needle on slit-lamp exam, eye burr

Complication of metallic FB: rust ring or corneal perforation (open globe)

• Rust rings can form within only a few hours
• Update Tdap
• Consult ophthalmology

Antibiotic:

• Moxifloxacin (Vigamox), ofloxacin, ciprofloxacin drops
  • Require pseudomonal coverage for contact len wearers
• Erythromycin ointment

Consult ophthalmology if unable to remove FB, visual deficit, concern for open globe, or rust ring

Follow-up with optho – 24-48 hrs

Nasal Foreign Body:

Removal Techniques:

• Mother’s Kiss Technique
• Suctioning
• Forceps with nasal speculum
• Dermabond on Q-tip
• Foley catheter, Fogarty catheter or Katz extractor

Complications:

• Soft tissue injury – epistaxis, septal injury/hematoma, nasopharyngeal trauma
• Barotrauma
• Displacement of FB into airway

Disposition:

• Discharge home following FB removal in uncomplicated cases
• Antibiotics if concern for infection
• ENT consult if unable to remove FB or persistent epistaxis

Pharmacy Lecture

Presenter: Nicholas Cottrell, Pharm.D

Intranasal Meds:

Adv:

• Ease of use
• Rapidly effective
• Relatively safe

Metabolism:

• Metabolized by liver
• Nasal meds bypass liver metabolism
• Optimizing drug intranasal:
  • 0.2-0.3 ml, Never more than 1 mlà will cause post nasal drip
  • Remove blood and mucous from the nose
  • Use both nostrils
  • Use atomized delivery system

Go to Treatment for Headache:

• Sphenopalatine Ganglion Nerve Block:
  • Associated with trigeminal nerve
  • Seen in migraine and cluster HA
  • How to perform Sphenopalatine Ganglion Nerve Block
    • 10 cm cotton tip applicator
    • Anesthetic 1% lido
    • 5 cc syringe with large bore needle to draw up anesthetic

Angioedema:

• Hereditary
  • Recurrent attacks
  • C1 esterase inhibitor deficiency
  • Allergic reaction meds are ineffective
• Acquired Angioedema
  • Rare
• Treatment:
  • Green Zone: Minimal edema
    • Observation
  • Yellow: Moderate
    • Watch, meds
  • Red Zone: Immediate need for intubation
    • Stridor
    • Dyspnea
    • Progressive deterioration

Intubations Hazards:

• Airway manipulation may worsen swelling
• Laryngeal edema will preclude use of LMA

TXA:

• TXA can work on bradykinin mediated angioedema
• 1 g IV push over 10 minutes, q4h PRN
  • ADE: Thrombosis
• C1 esterase deficiency angioedema:
  • 2 units of FFP initially, 2 units PRN
  • Other meds:
    • Icatibant and Ecallentide
      • Take longer to work
      • Not always available
      • EXPENSIVE

Management of Obligate Neck Breathers

Presenter: Dr. Shawn Jones, Otolaryngology PGY-2

• Tracheostomy:
  • Exteriorizes trachea to skin of neck for permanent gas exchange:
    • Why:
      • Severe OSA
      • Head and neck cancers or masses
      • Subglottic stenosis
      • Ludwig’s angina
      • Paralysis of vocal cords
      • Prolonged ventilator support
    • Benefits:
      • Reducing need for sedation
      • Improve patient comfort
      • Reduce ventilator pneumonia
    • Risks:
      • Infections
      • Bleeding
      • Fistula
      • Granulation tissue and scarring
      • Tracheal occlusion:
        • Mucus plugging
        • Accidental decannulation

Tracheostomy and Respiratory Distress:

1. Remove trach cap

2. Attempt to pass suction catheter to assess patency

3. Provide supplemental O2 (trach collar, BiPAP, bagging)

4. Replace uncuff trach tube with cuffed trach tube or cuffed ET Tube to provide PPV

Image Source: https://aneskey.com/what-is-a-tracheostomy-what-is-a-laryngectomy/

Laryngectomy

• Larynx is surgically removed
• Upper airway no longer connects to trachea
• Trachea is fixed to skin to create permanent stoma

Indication:

• Cancer of head and neck
• Chronic aspiration

TEP = transesophageal prothesis – may be placed after laryngectomy to allow for speech

Image Source: https://sinaiem.org/dont-fear-the-tracheostomy/

Laryngectomy and respiratory distress:

• Provide supplemental O2: trach-collar, BiPAP, bagging
• Must place cuffed ET tube to provide PPV (lary tubes are uncuffed)

Image source: https://www.pinterest.com/pin/117586240255365772/

Pediatric Heme/Onc Emergencies

Dr. Julie Klensch, Pediatric EM Fellow

Hemorrhagic Disease of Newborn

• Vit K deficiency causes severe bleeding
• Onset usually during 1^st week of life
• ICH, intrathoracic or intracranial bleeding, oozing from mucous membranes

Treatment:

• Vit K and FFP
• Transfuse for Hgb<7
• pRBC 10-15 ml/kg given over 2-4 hrs
• 10 ml/kg should increase Hgb by ~2

Hemolytic anemia

• Pallor, jaundice, dark urine, fatigue, dizziness
• Intrinsic vs extrinsic
• Evaluation: CBC, CMP, LDH, haptoglobin, direct/indirect bilirubin , Comb’s test in newborns

Sickle Cell disease

• Vascular occlusion
• Infection
• End organ damage
• Tx: analgesia and hydration
• Salmonella + sick cell patient = osteomyelitis

Dactylitis

• Vaso-occlusive crises of hands and feet; often initial presenting sign of SS disease

Splenic Sequestration

• Splenomegaly, thrombocytopenia, LUQ pain

Acute chest syndrome

• Infiltrate of CXR, chest pain, hypoxia
• Tx: ceftriaxone and azithromycin, IVFs, consider pRBC transfusion if respiratory support required

Stroke

• Management: CT, MRI, exchange transfusion

Avascular necrosis:

• Leg/hip pain, inability to bear weight
• Tx: analgesia and orthopedics consult

Infection

• Hyposplenia leaves patient at risk from encapsulated organism, specifically S. Pneumoniae
• Children < 5yo should be on prophylactic penicillin.

Thrombocytopenia

• Plt transfusion 5-10 ml/kg, rate dependent on urgency
• 1 U increase 5,000-10,000

Immune thrombocytopenia (ITP)

• Well appearing child, unexplained petechiae and bruising, isolated thrombocytopenia following viral infection
• Tx: IVIG, don’t transfuse plt

Neutropenia

• ANC<1500, severe ANC<500
• Fever + Neutropenia = septic work-up with administration of broad-spectrum antibiotics

Tumor Lysis Syndrome

• Initiation of chemotherapy; most common in leukemia or lymphoma (high cell turnover)
• Hyperkalemia, hyperphosphatemia, and elevated uric acid
• Tx: Allopurinol and hydration, Rasburicase for severe cases but expensive

Lateral Canthotomy – Procedure SIM

Presenter: Dr. Michael Carter and Dr. Ross Sizemore

Indication for lateral canthotomy: Ocular compartment Syndrome

• Most commonly due to blunt trauma
  • Retrobulbar hematoma/hemorrhage
  • Infection, orbital emphysema, FB (less common)
• Eye Pain, proptosis, difficulty open eyelids, pain/difficulty with EOM
• Perform pupillary exam, visual acuity, and tonometry (IOP>40)
• Order CT but do not delay treatment
• Irreversible vision loss may occur within 60-100 min if not treated

Globe rupture: contraindication to the procedure

Medical management:

• Elevate HOB, analgesia, and BP control, antiemetics
• IV acetazolamide
• Timolol eye drops
• IV mannitol

Pitfalls:

• Lack of early recognition and ophthalmology consultation
• Iatrogenic injury
• Incomplete resolution

Equipment:

• Chlorhexadine
• Lidocaine w/ epi
• Needle and syringe for lidocaine injection
• Straight mosquito hemostat
• Iris scissors
• Forceps

Procedure Tips:

• Angle sharps away from eye during procedure
• Recheck IOP after procedure
• Be aware of lacrimal gland if cutting superior tendon.

Image Source: https://www.tamingthesru.com/blog/annals-of-b-pod/ocular-emergency

Ceasing Resuscitation in the Pre-Hospital Setting

Presenter: Dr. Raymond Orthober

Termination of out of hospital cardiac arrest (OHCA)

• Non-traumatic patients
• 0.6% survival rate in those with ROSC >25 min CPR
• In most situations, ACLS initial resuscitation on scene is equivalent to ACLS offered in-hospital
• Goal: Gain ROSC and obtain good neurological outcome

Load-and-Go vs Stay-and-Play

• Trauma = Load-and-Go
• Medical = Stay-and-Play

Withholding resuscitation efforts: Evaluate life status

• Cold and stiff in warm environment
• Rigor Mortis
• Lividity
• Obvious mortal wounds
• Obvious signs of decomposition
• Valid DNR

Determination of death:

• Pupils fixed and dilated
• Apnea
• Pulseless
• Asystole in 2 leads

Exceptions to cease resuscitation in the field: cold water drowning, electrical injury, hypothermia

CPR underway & request to cease resuscitation:

• No bystander CPR
• No witnessed arrest
• No response after >6 min high quality CPR
• No shockable rhythm
• Asystole in 2 leads
• No ROSC at anytime
• 20-25 min CPR prior to request to cease resuscitation

EtCO2

• EtCO2 > 20 is a sign of life
• EtCO2 < 10 may be used to support termination of CPR
• Technical difficulties may lead to inaccurate EtCO2
• Use as complementary value in bigger picture of patient

Radio call – Questions to ask

1. Valid DNR or MOST form?
2. Witnessed arrest and/or bystander CPR?
3. Definitive airway? iGel, LMA, ETT
4. Any shocks delivered?
5. ROSC at any point?
6. Asystole at time of call?
7. 20-25 min CPR?
8. EtCO2<10

Termination of Resuscitation in Trauma

• Trauma = Load-and-Go
• All trauma patients should be transported except in rare circumstance of obvious mortal wound, no signs of life, and prolonged downtime

Thromboelastography (TEG)

Presenter: Dr. Isaac Shaw

Utilize to guide your blood product resuscitation.

Trauma patients or severe UGI bleed presenting in hemorrhagic shock and requiring MTP in the ED.

Image Source: https://www.tamingthesru.com/blog/grand-rounds/teg

• Prolonged R-time –> administer FFP
• Decreased Alpha angle –> administer cryoprecipitate
• Decreased MA –> administer platelets
• Increased LY30 –> administer TXA

TEG turn-around time: Final result in ~30 minutes

Room 9 computer has TEG software – can begin to see graph form in 5-10 minutes.

Oral Boards Case

Presenter: Dr. Isaac Shaw

28 year-old male presents for hemoptysis in the setting of recent tracheostomy placement.

Differential diagnosis for bleeding tracheostomy site:

• Tracheoinnominate fistula
• Tracheal irritation
• Bacterial Tracheitis
• Surgical site bleeding or infection
• Pulmonary Embolism
• Diffuse Alveolar Hemorrhage

Sentinel bleed: small bleed prior to large volume hemorrhage due to tracheoinominate fistula formation

It takes ~1 week for tracheostomy tract to mature

Image Source: http://emdaily.cooperhealth.org/content/emconf-tracheoinnominate-fistula

Management:

1. Hyperinflate tracheostomy cuff (~40-50cc)

2. Consider replacing trach with standard ET tube and then hyperinflate ET tube cuff (may help if bleed is further down)

3. Insert fingers in trach site and apply pressure anteriorly against back of sternum

Image Source: Ailawadi G. Technique for managing Tracheo-innominate artery fistula. Operative Techniques in Thoracic and Cardiovascular Surgery. 2009;14(1):66-72. doi:10.1053/j.optechstcvs.2009.02.003

Image Source: Ailawadi G. Technique for managing Tracheo-innominate artery fistula. Operative Techniques in Thoracic and Cardiovascular Surgery. 2009;14(1):66-72. doi:10.1053/j.optechstcvs.2009.02.003

Lighting Lectures:

Presenter: Dr. Jordan Martinez and Dr. Adam Lehnig

Retropharyngeal Abscess

• Age: 2-4 years old most common
• Often presents after an infection, usually URI
• May be precipitated by trauma, dental procedure, intubation, etc
• Polymicrobial infection

Management:

• Evaluate for airway compromise –> ABCs
• Obtain CT soft tissue neck W (historically lateral neck X-ray was used)
• Antibiotics: IV Unasyn or IV Clindamycin
• Consult: ENT

Image Source: https://www.slideserve.com/derora/deep-neck-infections

Image Source: https://www.wikidoc.org/index.php/Retropharyngeal_abscess

Ludwig’s Angina:

• Bilateral infection of submandibular space
• Dental source = most common cause
• “Hardening of floor of mouth”
• Tongue swelling and elevation; neck swelling

Management:

• Evaluate for signs of respiratory distress: drooling, dyspnea, dysphonia, dysphagia
• Fiberoptic nasal intubation if necessary
• Consider CT imaging
• Antibiotics: IV Unasyn – first line
• Polymicrobial infection – consider broad spectrum if known MRSA or pseudomonal exposure
• ENT consult

Room 9 Follow-Up:

Presenter: Dr. Dylan Nichols

Two patient cases discussed. Both patients with bradycardia in the setting of acute renal failure and severe hyperkalemia. Both patients demonstrated transient bradycardia which eventually resolved.

BRASH Syndrome:

• Bradycardia
• Renal Failure
• AV blockade
• Shock
• Hyperkalemia

Consider in: Elderly patients with cardiac disease on BB/CCB

Trigger: hypovolemia or AKI

Image Source: https://litfl.com/brash-syndrome/

Epistaxis

Presenter: Dr. Matthew Eisenstat

Anterior Bleed (90%): comes from Kiesselbach’s plexus

Posterior Bleed: (10%): higher concern severe bleeding or arterial bleed (sphenopalentine artery)

May use nasal speculum for better visualization.

Image Source: https://www.aafp.org/afp/2018/0815/p240.html

Management:

1. Direct pressure (consider taping together tongue depressors)
2. Oxymetazoline (Afrin) spray – have patient blow nose to remove clots prior to application
   1. May also consider lidocaine w/ epinephrine or phenylephrine spray
3. Chemical cauterization with silver nitrate stick – do not apply bilaterally due to decrease flow to nasal septum
4. TXA soaked gauze/pledget or Surgicel gauze
5. Traditional nasal packing with Vaseline gauze
6. Nasal Tampon Device (Merocel) – expands when exposed with liquid, tape string to patient’s face
7. Nasal balloon device (Rhino-Rockets) – inflatable device applies direct pressure

Image Source: https://www.capesmedical.co.nz/medical-products/woundcare/epistaxis-control/epistaxis-rapid-rhino-device-unilateral-airway

Disposition:

• Admit posterior bleeds and severe anterior bleeds requiring nasal packing
• Consider admission in patients with multiple comorbidities or on anti-coagulation
• No definitive recommendation on blood pressure management in epistaxis
• If discharging recommend removal of nasal packing in 48-72 hours to avoid development of toxic shock syndrome

Nasal fracture:

• No imaging required in isolated injury
• Immediate reduction or reduction at follow up in:
  • Children: 2-4 days
  • Adult 6-10 days
• Nasal septal hematoma: requires immediate drainage followed by bilateral nasal packing and ENT follow-up within 24 hours
• Children + epistaxis: evaluate for foreign body

Ophthalmology for the ED Provider

Presenter: Dr. Sanket Shah, Ophthalmology PGY-4

Image Source: https://www.allaboutvision.com/resources/anatomy.htm

Eyelid lacerations

• Laceration involving eyelid border = ophthalmology consult
• Laceration to medial canthus = concern for disruption of lacrimal duct = ophthalmology consult

Visual acuity

• Check each eye individually
• With glasses on or utilize pin hole in patient >40 y/o
• Counting fingers, hand motion, light perception if patient unable to read eye chart

Pupillary exam

• Size, shape, response to light

IOP

• Utilize anesthetic drops and Tonopen
• Normal is up to ~21 mmHg; in the ED up to 30 mmHg is reasonable
• Ensure no pressure on the eye from hands; patient no holding their breath during exam

Subconjunctival hemorrhage

• may follow-up in clinic

Subconjunctival hemorrhage + chemosis

• depends on severity and percent of chemosis; consider ophthalmology consult in severe cases

Corneal abrasion

• Evert eyelids and exam – utilize cotton tip
• Evaluate with fluorescein staining
• Small, normal vision
  • erythromycin ointment QID 4-5 days
• In setting of wood, sticks, fingernail, contacts
  • moxifloxacin eye drops
  • avoid ciprofloxacin drops due eye toxicity
• Large, central, concern for corneal ulcer:
  • Immediate ophthalmology consult
  • Antibiotic drops

*Never discharge patients with anesthetic eye drops (tetracaine or proparacaine); Toradol drops are a safe option

Foreign body removal

1. damp cotton swab
2. 18g needle
3. Eye burr – recommend ophthalmology consult prior to trying this

Chemical burns

• Check pH prior to application of any drops
• Irrigate copiously and recheck pH
• Consider Morgan Lens

Corneal Ulcer

Staining corneal ulcer = Ophthalmology emergency and immediate consult

Traumatic Iritis

• Blunt trauma
• Visual deficit = ophthalmology consult
• Tx: dilating drops (cyclopentolate); Ophthalmology may start steroids

Hyphema

• >50% consider ophthalmology consult

• Consult ophthalmology in all sickle cell patients

Orbital Fracture

• Ophthalmology requests full eye exam prior to consult
• Entrapment higher concern in pediatric population

Retrobulbar hemorrhage

• Ophthalmology Emergency – Immediate consult
• Check IOP
• Consider lateral canthotomy if increased IOP, decreased visual acuity, or proptosis present

Image Source: https://www.tamingthesru.com/blog/annals-of-b-pod/ocular-emergency

Ruptured Globe

• Ophthalmology Emergency – Immediate consult
• Apply eye shield
• Obtain CT Orbits WO
• Update Tdap
• Broad Spectrum Antibiotics: Prefer Vancomycin and Levaquin

Painful Vision Loss:

• Acute angle closure glaucoma
  • IOP lowering drops

Image Source: https://www.tamingthesru.com/blog/annals-of-b-pod/b-pod-case/angle-closure-glaucoma

• Optic neuritis
  • MRI Brain/Orbit W&WO
  • Neurology consult
• Uveitis
• Endophthalmitis
• Corneal hydrops

Painless Vison Loss:

• Giant Cell Arteritis (GCA)
• Central Retinal Artery Occlusion (CRAO)
• Central Retinal Vein Occlusion (CRVO)
• Retinal Detachment
  • Utilize ultrasound for evaluation

Image Source: https://jetem.org/retinal_detachment/

• Vitreous Hemorrhage
• Amaurosis Fugax

Chronic Eye Disease:

• Cataracts
• Open angle glaucoma
• Dry eye
• Diabetic retinopathy
• Macular degeneration

I have recently seen many patients sent to the ED from urgent care centers and PCP offices for evaluation of hypertension. While true hypertensive emergency often leads to straight forward disposition, this condition is rare and much more commonly patients present with severe asymptomatic hypertension (sometimes referred to as hypertensive urgency). I will discuss an approach to management of these conditions below.

Image source: https://epmonthly.com/article/dont-let-hypertension-stress/

Common causes of hypertension:

• Medication noncompliance
• Pain
• High-salt diet
• Amphetamine or stimulant use
• Alcohol withdrawal or drug withdrawal

Less common causes of hypertension:

• Pheochromocytoma
• Thyroid Storm
• Intracranial hemorrhage
• Preeclampsia/Eclampsia

Special considerations in hypertension:

• Ischemic/hemorrhagic stroke
• Aortic Dissection

Hypertensive Emergency: Severe hypertension, commonly defined as BP > 180/120, with signs of end-organ damage.

End-organ damage:

• Neurological: intractable headache, vision changes, ischemic or hemorrhagic stroke, hypertensive encephalopathy or PRES
• Cardiac: chest pain, EKG changes or elevated cardiac biomarkers indicative of cardiac stress
• Pulmonary: dyspnea, pulmonary edema
• GI: abdominal pain, nausea/vomiting, transaminitis
• Renal: AKI, proteinuria, electrolyte abnormalities

Image Source: https://em3.org.uk/foamed/8/6/2016/hypertensive-crisis

Work-up:

• CBC
• CMP
• EKG
• Troponin
• Chest X-ray
• Urinalysis
• β-hCG in females
• Consider Head CT if neurological symptoms

Management:

Treatment with IV anti-hypertensives and admission to appropriate service, usually medicine or cardiology.

Common IV anti-hypertensives:

• labetalol IV push (5-20 mg)
• hydralazine IV push (10-20 mg)
• nicardipine drip (start at 5 mg/hr and titrate to goal BP)
• nitroglycerin drip – specifically for acute pulmonary edema (see SCAPE management for dosing)

BP Goal: reduction in MAP by 10-20% in the first hour followed by gradual reduction in MAP by ~25% over the first 24 hours.  Commonly a goal BP of ~160/100 achieves goal of 10-20% reduction.

*There is increased risk of cerebral and cardiac ischemia if lowering BP too rapidly

Exceptions:

• Hemorrhagic CVA and aortic dissection have specific guidelines for BP goals and rapid lowering
• Ischemic CVA allow for permissive hypertension

*Beta-blocker contraindicated in amphetamine intoxication and pheochromocytoma

• amphetamine intoxication – use benzodiazepine
• pheochromocytoma – use alpha-blockers (phentolamine)

Severe asymptomatic hypertension (hypertensive urgency): Severe hypertension, commonly defined as BP > 180/120, with no signs of end-organ damage.

*Some physicians strongly dislike the term “hypertensive urgency” and ACEP utilizes the term “asymptomatic severely elevated blood pressure”.

This is a diagnosis of exclusion. As an ED physician it is your job to first rule out hypertensive emergency.

Management of severe asymptomatic hypertension:

* The first 3 steps below should apply to any patient presenting for hypertension.

1. Place patient in a quiet and relaxing environment (when possible)
2. Administer patient’s home PO anti-hypertensives if not taken today
3. Control patient’s pain and treat any underlying causes
4. Consider additional PO or IV anti-hypertensives
   1. PO anti-hypertensives
      1. Captopril (6.25-50 mg)
      1. Enalapril (2.5-20 mg)
      1. Clonidine (0.1-0.2 mg) *Would avoid due to variable response
   1. IV anti-hypertensives
      1. labetalol IV push (5-20 mg)
      1. hydralazine IV push (10-20 mg)
5. BP reassessment following administration

Goal BP prior to discharge:

• Ideally BP ~160/100
• In a completely asymptomatic patient, BP ~180/110 or even higher may be acceptable with appropriate follow-up
• No definitive recommendation exists for a blood pressure cut-off for which an asymptomatic patient must be acutely treated
• Many physicians have personal practice patterns and different comfort levels with this

Discharge Medications:

• If initiating home PO anti-hypertensives common medications include:
  • Amlodipine (5-10 mg)
  • Hydrochlorothiazide (HCTZ 12.5-25 mg)
• May considering increasing current home anti-hypertensive dose but would avoid this in most circumstances
• Once again, many physicians have personal practice patterns and different comfort levels with initiating or increasing doses of antihypertensives from the ED

Image source: https://epmonthly.com/article/dont-let-hypertension-stress/

Follow-up:

• All patients should be provided resources for appropriate outpatient management
• Recommend repeat BP check within several days
• Recommend repeat renal function testing within 1 week if initiating anti-hypertensive therapy or increasing ACE or ARB

References:

1. UpToDate: Evaluation and treatment of hypertensive emergencies in adults
2. UpToDate: Management of severe asymptomatic hypertension (hypertensive urgencies) in adults
3. TamingTheSRU: Clinical Practice Guidelines: Hypertension
4. https://epmonthly.com/article/dont-let-hypertension-stress/
5. https://em3.org.uk/foamed/8/6/2016/hypertensive-crisis