10 things I wished I knew before my first shift as an intern

  1. Do your simplest tasks first, knock them out and don’t wait to do anything!
  2. Always push yourself. Being comfortable is comfortable, but this is not how you learn. Always try to pick up one more patient, challenge yourself to do things more efficiently. In the end books do not teach you how to survive in this specialty, seeing more is knowing more.
  3. Don’t be afraid to ask for help. That is what everyone is here for. Emergency medicine is a team sport. If you are not comfortable doing a procedure, aren’t able to do the procedure, just ask for help.
  4. On that same note, don’t be afraid to ask in general. This is your time to learn, and this is your moment to pick your seniors/attendings brain. Try to figure out what their thought process is, and what their style of practice is and why.
  5. Hydrate and stay well hydrated. Bring a bottle, fill it before your shift. Drink at least 1-2 of these. Also visit a restroom every once and a while. Full bladder = agitation.
  6. Request off for things well in advance. Or else you won’t be off and will have to beg people to cover your shifts. Look in advance for weddings, birthdays, other special things during the year and request off now.  Seriously, go do it. If your program pays for you to go to a conference make sure you ask off for this as well.
  7. Stay on top of your administrative duties. They are no fun, but they are even less fun 3 months from now when your program director is angry and your classmates have to cover your shift because you don’t have your login ready in time. Log everything as soon as you can- procedures, ultrasounds, competencies, etc. When you log into your work station at the beginning of your shift also open up the logging system your program uses so you can log right away. Stalling = lost opportunities.
  8. Find out if your state has a health information exchange portal and or a prescription drug monitoring. program and register STAT. This is not only clinically helpful, you will look like a rock star if you are able to inform your team of that recent narc script or CT scan performed at Across The Street hospital.
  9. Find a mentor. Be a mentor. Find an attending and/or senior with shared interests and a compatible personality to help you with career advise, personal life balance, etc. These relationships can last a lifetime, and can lead to great things in the future. Give that back to an intern next year or a medical student you get along with. It is one of the most rewarding things you will do.
  10. Be nice to everyone. Nurses, the cleaning staff, the lady at the parking lot booth. You never know when these people might save your life someday. Plus it makes your shift more fun when you know everyone. Ask your consultants to help out with procedures- they can teach you how to do things differently that are useful when you are on your own one day. Teach them some. Karma and such.

Written by: Bennett Myers, M.D. | Edited by: Maite Huis in ‘t Veld, M.D. | June 23rd, 2015


Hypertensive Emergencies

Say what?

Hypertensive emergency has no universally accepted definition. Actual numbers are often used to define hypertensive emergency, though strictly speaking a hypertensive emergency is any elevation in blood pressure in the presence of end-organ dysfunction.1,2,3

Aggressively treating severe asymptomatic hypertension (very high blood pressure without clear end organ damage) is not indicated, not supported by the literature and dangerous. First, do no harm.

No end-organ damage ≠ HTN emergency

Pathophys alert: the mechanism of HTN emergency is poorly understood but it generally results from an abrupt rise in systemic vascular resistance, direct endothelial injury, and a loss of the body’s ability to autoregulate flow in vital organs. This leads to a continued increase in BPs and end organ damage. 2,4,5 Furthermore extremes of pressure result in activation of the renin-angiotensin-aldosterone axis. This leads to further vasoconstrictor release and elevations in BP. Finally, many patients undergo a pressure-induced natriuresis. The resulting intravascular volume loss causes further mediator release that elevates BP.

Your patient may report (from most to least common) 6:

  • Dyspnea (up to 30%)
  • Chest pain
  • Headache
  • Altered Mental Status
  • Limb weakness or sensory changes
  • Seizures (eclampsia)

You should ask about:

  • History of hypertension
  • Compliance with medication
  • Illicit drug use
  • Pregnancy
  • Kidney disease

On physical examination you should look for: 

  • Changes in mental status
  • Focal neurological abnormalities
  • Papilledema
  • Rales
  • JVD/S3
  • Asymmetric blood pressures between limbs

Is this really it?

If you patient has an elevated blood pressure in the setting of end organ dysfunction, then yes, it is.

If there are no clear signs of end organ damage, then no, it isn’t.

What tests does my patient need?

When evaluating your hypertensive patient it is imperative to make the distinction between a patient with symptomatic and asymptomatic hypertension. The recommendations below are for symptomatic patients only. Testing is mostly based on your patient’s presentation.

Labs: obtain a creatinine to assess for renal failure. A troponin and BNP are indicated if your patient has signs and symptoms consistent with cardiac ischemia or pulmonary edema.

Urine: perform a urinalysis to assess for proteinuria, indicating renal failure. If a pheochromocytoma is suspected obtain urine metanephrines. Obtain a toxicology screen if illicit drug use is suspected.

ECG: obtain if your patient has chest pain, shortness of breath, or signs and symptoms of pulmonary edema. Assess for ischemic changes.

Chest X-ray: indicated if pulmonary edema is suspected.

CT/MRI-scan: a CT-scan of the chest is indicated if an aortic dissection is suspected. CT scan of the brain should be obtained in a patient who has a history and/or physical examination consistent with an ischemic or hemorrhagic stroke. An MRI is more sensitive than a CT-scan for detecting changes consistent with hypertensive encephalopathy.

Is there a cure, doc?

For HTN emergencies, first, do no harm. Traditionally, a reduction of your patient’s mean arterial pressure (MAP) of no more than 20-25% in the first hour of treatment has been recommended. Several studies have indicated that we often do not do this well, and that we drop our patient’s blood pressure too rapidly in the emergency department. 7 Rapid lowering of the blood pressure poses your patient at risk of ischemic events (occurring in up to 5% of patients with rapid blood pressure reduction), and should be avoided at all cost. Aim for a reduction of 15-20% in the first hour, and no more than 25% in first 2 hours. It is important to monitor your patient’s blood pressure very closely. For that reason, an arterial line is highly recommended in HTN emergency. 6,9,10

What is the best route of drug administration?

A continuous, short acting, titratable intravenous agent is indicated for initial treatment. A continuous infusion is likely to achieve more predictable blood pressure control compared to repeated doses of antihypertensives. Oral and transdermal antihypertensives are not indicated in hypertensive emergency. These agents have a high failure rate and cannot easily be reversed.

Which agent should I use?

There are few studies with head to head comparison of agents in HTN emergency. One 2011 study suggested nicardipine, when compared to labetalol, may be superior in time to BP reduction, less adverse events and less need for use of additional agents. 11 Of note: most of the studies comparing nicardipine to labetolol are manufacturer sponsored. None of these studies report patient centered outcome differences (i.e. mortality benefit).

Consider the agents below depending on the specific end organ damage: 7,10,11

Medication End Organ Damage Pearls
Nicardipine Aortic Dissection
Renal Failure
HTN encephalopathy
Hemorrhagic or ischemic stroke
If used in dissection, must give beta blocker first
Clevidipine Aortic Dissection
Renal Failure
HTN Encephalopathy
Hemorrhagic or ischemic stroke
Fast onset and shorter half life than nicardipine makes, hence, very titratable but not available in many institutions
Labetalol Aortic Dissection
Pre-eclampsia and eclampsia
Hemorrhagic or ischemic strokes
Safe in pregnancy
Can be used as signal agent in aortic dissection
Nitroglycerin Acute Pulmonary Edema
Acute Coronary Syndrome
May use sublingual or topical forms until IV access established
Esmolol Aortic Dissection Should be used before vasodilator in dissection
Bolus initially and then begin continuous infusion
Phentolamine Cocaine or amphetamine intoxication
Pheochromocytoma
Secondary treatment with cocaine or amphetamines after trial of benzodiazepines
Fenoldopam Acute Renal Failure
Furosemide Acute Pulmonary Edema Not a first line agent as patients are generally hypovolemic; furosemide is also slow to work so should be used as an adjunctive agent

 

Additional Treatment Pearls:

  • Aortic dissection: if your patient has aortic dissection, rapidly lower the heart rate to approximately 60 beats per minute to help prevent reflex tachycardia. Once the heart rate is controlled, rapidly lower the SBP to < 120 mm Hg. Aortic dissection is the one HTN emergency where the rule of a 15-20% reduction in MAP during the first hour does not apply.
  • There is no clear data to prove that aggressive blood pressure lowering reduces hematoma expansion if your patient has a intracerebral hemorrhage, however, early high blood pressures are associated with mortality. 12 Therefore, aggressive blood pressure management should be considered, and recent data indicated that this may be safe. 13,14,15
  • In stroke patients, blood pressure targets are guided by stroke subtype and presenting blood pressure. 12 Start with a MAP reduction of 15-20% in the first hour in the ED.

Miller table stroke SBP

  • Eclampsia: give intravenous magnesium sulfate combined with labetolol. Definitive treatment is delivery of fetus.
  • A headache does not equal hypertensive encephalopathy. Hypertensive encephalopathy is diagnosed after a CT scan of the brain ruled out a bleed or stroke. 9
  • Give IVF fluids – most patients with hypertensive emergency are intravascularly depleted. Providing IV fluids can help prevent dropped blood pressures after initiation of antihypertensives. 16,17

FOAM under pressure: blow of some steam with continued reading/listening

Beginner

Intermediate

Advanced

References

1. Chobanian AV, Bakris LG, et al. Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension. 2003; 42:1206-52.

2. Kessler CS and Joudeh Y. Evaluation and treatment of severe asymptomatic hypertension. AFP. 2010; 81: 470-476.

3. Wolfe SJ, Lo B, et al. Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Em Med. 2013; 62: 59-64.

4. Vaughan CJ and Delanty N. Hypertensive emergencies. The Lancet. 2000; 356: 411-7.

5. Papadopoulos DP, Mourouzis I, et al. Hypertension crisis. Blood Pressure. 2010; 19: 328-36.

6. Marik PE and Rivera R. Hypertensive emergencies: an update. Current Opinion in Critical Care. 2011; 17: 569-580.

7. Brooks TWA, Finch CK, Lobo BL, et al. Blood pressure management in acute hypertensive emergency. Am J Helath-Syst Pharm. 2007; 64: 2579-2582.

8. Emergency Medicine Updates – Hypertension and the Emergency Physician

9. Johnson W, Nguyen M, Patel R. Hypertension in the emergency department. Cardiol Clin. 2012; 30: 533-543.

10. Flanigan JS and Vitberg D. Hypertensive emergency and severe hypertension: what to treat, who to treat, and how to treat. Med Clin N AM. 2006;90:439-451.

11. Peacock WF, Varon J, et al. CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department. Critical Care. 2011; 15: R157-64.

12. Miller J, Kinni H, Lewandowski C, Nowak R, Levy P. Management of hypertension in stroke. Ann Emerg Med. 2014 Sep;64(3):248-55.

13. Zazulia, A.R., Diringer, M.N., Videen, T.O. et al. Hypoperfusion without ischemia surrounding acute intracerebral hemorrhage. J Cereb Blood Flow Metab. 2001; 21: 804–810

14. Anderson CS, Heeley EH, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intacerebral hemorrhage. NEJM. 2013; 368:2355-2365.

15. Anderson CS, Huang Y, Wang JG, et al. Intensive blood pressure reduction in acute cerebral haemorrhage trail (INTERACT): a randomized pilot trial. Lancet Neurol. 2008; 7: 391-9.

16. Marik PE, Rivera R. Hypertensive emergencies: an update. Curr Opin Crit Care 2011; 17:569-80.

17. UMEM Education Pearls- Hypertensive Emergencies

 

Written by: Phil Magidson, M.D., M.P.H. | Edited by: Maite Huis in ‘t Veld, M.D. | Peer reviewed by: Michael Winters | November 9th, 2014