Hypertensive Emergencies

Presentation

This may be asymptomatic or may present with any of the many symptoms and signs of end-organ damage:

• Headache
• Fits
• Nausea and vomiting
• Visual disturbance
• Chest pain
• Neurological deficit
• Bleeding due to disseminated intravascular coagulopathy
• Microangiopathic haemolytic anaemia

(Thomas H. 2011)

Figure 1 - Hypertensive emergencies in children and adolescents
Source - www.netterimages.com

Causes

• Unilateral renovascular hypertension (Ex: renal artery stenosis)
• Renin-secreting neoplasms
• Trauma to the kidneys
• Renal vasculitis (Ex: scleroderma, polyarteritis andsystemic lupus erythematosus)
• Phaeochromocytoma
• Cocaine abuse
• Drugs such as monoamine-oxidase inhibitors, combined oral contraceptives or the withdrawal of alcohol, alpha stimulants such as clonidine, or beta-blockers.
• Sodium-volume overload and low renin levels (Ex: acute glomerulonephritis, primary aldosteronism)
• Pre-eclampsia/ eclampsia
• Hyperthyroidism
• Hypothyroidism

 (Thomas H. 2011)

Investigations

• Full history - including:

1. -       Past medical history
2. -       Full systems review
3. -       Drug history including over-the-counter, herbal remedies and recreational drugs

• Full examination - including:

1. -       Blood pressure measurements
2. -       Fundoscopy
3. -     Cardiovascular examination (look for signs of cardiac failure or pulmonary edema, carotid or renal bruits, left ventricular heave, cardiac murmurs, third or fourth heart sounds)

-       Neurological examination

• Blood tests:

1. -       FBC ± clotting screen
2. -       U&Es, creatinine
3. -       Liver and TFTs
4. -       Blood sugar measurement
5. -       ± Cardiac enzymes and fasting blood lipids

• ± Ambulatory blood pressure monitoring
• Urine dip testing for protein and blood
• CXR (cardiac size, cardiac failure, etc.)
• ECG (left ventricular hypertrophy or left atrial enlargement)
• Subsequent investigations may include:

1. -       CT/MRI scan of the head or kidneys
2. -       Plasma renin activity
3. -       Plasma aldosterone level
4. -       24-hour urine for vanillylmandelic acid (VMA) and catecholamine levels.
5. -       Auto-antibody levels (Ex: antinuclear factor)

 (Thomas H. 2011)

Stepwise Management

• Initially, try to reduce the mean arterial pressure by approximately 25% over the first 24-48 hours.
• An arterial line is helpful for continuous blood pressure monitoring.
• There may be severe sodium and volume depletion; volume expansion with isotonic sodium chloride solution may be required.
• Drugs

-       Intravenous route is usually used. Nitroprusside is the most commonly used IV drug.

-       Phentolamine is the drug of choice for a phaeochromocytoma crisis.

 (Thomas H. 2011)

REFERENCES

Thomas H. 2011. Patient.co.uk. [ONLINE] Available at: http://www.patient.co.uk/doctor/hypertensive-emergencies [Accessed 27^th April 15].

Septic Shock

Presentation

Septic shock can affect any part of the body, including the heart, brain, kidneys, liver, and intestines. Symptoms may include:

• Cool, pale arms and legs
• High or very low temperature, chills
• Light-headedness
• Little or no urine
• Low blood pressure, especially when standing
• Palpitations
• Rapid heart rate
• Restlessness, agitation, lethargy, or confusion
• Shortness of breath
• Skin rash or discoloration

(Hadjiliadis D. 2014.)

Causes

• Sepsis can be caused by any type of bacterial, fungal, or viral infections. Sepsis commonly originates from:

1. -       Abdominal or digestive system infections
2. -       Lung infections like pneumonia, bronchitis, or lower respiratory tract infections.
3. -       Urinary tract infection
4. -       Reproductive system infection

• This condition is especially prevalent in newborns, older people, pregnant women, and those with suppressed immune systems such as HIV or cancer patients.
• The following factors can also make it more likely that a person develop septic shock:

1. -       Major surgery or long-term hospitalization (increased risk of bacteria)
2. -       Diabetes Mellitus
3. -       Injection drug use
4. -       ICU patients
5. -       Exposure to invasive devices such as IV catheters or breathing tubes, which can introduce bacteria into the body

(Johnson S.)

Investigations

• Blood tests to check for:

-       Infection around the body

-       Low blood oxygen level

-       Disturbances in the body's acid-base balance

-       Poor organ function or organ failure

• Other tests:

-       Chest x-ray to look for pneumonia or pulmonary edema

-       Urine sample to look for infection

(Hadjiliadis D. 2014.)

Stepwise Management

• Breathing machine (mechanical ventilation)
• Dialysis
• Drugs to treat low blood pressure, infection, or blood clotting
• Fluids given directly into a vein (intravenously)
• Oxygen
• Sedatives
• Surgery

 (Hadjiliadis D. 2014.)

REFERENCES

Hadjiliadis D. 2014. Medline Plus.  Medline Plus. [ONLINE] Available at: http://www.nlm.nih.gov/medlineplus/ency/article/000668.htm [Accessed 27^th April 15].

Johnson S. (nd.) Healthline. [ONLINE] Available at:  http://www.healthline.com/health/septic-shock#CausesandRiskFactors3 [Accessed 27^th April 15].

Anaphylaxis

Presentation

Symptoms develop quickly, often within seconds or minutes. They may include any of the following:

• Abdominal pain
• Abnormal breathing sounds
• Anxiety
• Chest discomfort or tightness
• Cough
• Diarrhea
• Difficulty breathing
• Difficulty swallowing
• Dizziness or light-headedness
• Hives, itchiness
• Nasal congestion
• Nausea or vomiting
• Palpitations
• Skin redness
• Slurred speech
• Swelling of the face, eyes, or tongue
• Unconsciousness
• Wheezing

(Stuart I. 2014)

Causes

Anaphylaxis is a severe, reaction to a chemical that has become an allergen, a substance that can cause an allergic reaction.

Anaphylaxis can occur in response to any allergen. Common causes include:

• Drug allergies
• Food allergies
• Insect bites/ stings

(Stuart I. 2014)

Investigations

• Examine the person and ask about what might have caused the condition, any particular foods seem to cause a reaction, any medications, or any insect bite.
• Tests for the allergen that caused anaphylaxis if the cause is not obvious. (Stuart I. 2014)
• Tests for allergies with skin tests or blood tests. (Mayo Clinic. 2013)

Stepwise Management

• Check the person's airway, breathing, and circulation. If necessary, begin rescue breathing and CPR
• Calm and reassure the person.
• If the allergic reaction is from a bee sting, scrape the stinger off the skin with something firm. Do not squeeze the bee sting as it can release more venoms.
• Take steps to prevent shock.

 (Stuart I. 2014)

• Medications:

-              - Epinephrine (adrenaline) to reduce the body's allergic response

-              - Oxygen, to help compensate for restricted breathing.

-          - IV antihistamines and cortisone to reduce inflammation of the air passages and improve breathing.

-              - A beta-agonist to relieve breathing symptoms.

(Mayo Clinic. 2013)

REFERENCES

Stuart I. 2014. Medline Plus. [ONLINE] Available at: http://www.nlm.nih.gov/medlineplus/ency/article/000844.htm [Accessed 27^th April 15].

Mayo Clinic. 2013. Mayo Clinic. [ONLINE] Available at: http://www.mayoclinic.org/diseases-conditions/anaphylaxis/basics/treatment/con-20014324 [Accessed 27^th April 15].

Snake Bites

Figure 1 : A snake bite
Source - www.nlm.nih.gov

Presentation

Symptoms depend on the type of snake, but may include:

• Bleeding from wound
• Blurred vision
• Burning of the skin
• Convulsions
• Diarrhea
• Dizziness
• Excessive sweating
• Fainting
• Fang marks in the skin
• Fever
• Increased thirst
• Loss of muscle coordination
• Nausea and vomiting
• Numbness and tingling
• Rapid pulse
• Tissue death
• Severe pain
• Skin discoloration
• Swelling at the site of the bite
• Weakness

Figure 2 : Symptoms of snake bite
Source - www.wildbackpacker.com

Symptoms of rattlesnake bites include:

• Bleeding
• Breathing difficulty
• Blurred vision
• Eyelid drooping
• Low blood pressure
• Nausea and vomiting
• Numbness
• Pain at site of bite
• Paralysis
• Rapid pulse
• Skin color changes
• Swelling
• Tingling
• Tissue damage
• Thirst
• Tiredness
• Weakness
• Weak pulse

Symptoms of cottonmouth and copperhead bites include:

• Bleeding
• Breathing difficulty
• Low blood pressure
• Nausea and vomiting
• Numbness and tingling
• Pain at site of bite
• Shock
• Skin color changes
• Swelling
• Thirst
• Tiredness
• Tissue damage
• Weakness
• Weak pulse

Coral snake bites may be painless at first. Major symptoms may not develop for hours. Untreated coral snake bites can be deadly. Symptoms may include:

• Blurred vision
• Dyspnea
• Convulsions
• Drowsiness
• Eyelid drooping
• Headache
• Hypotension
• Excessive salivation
• Nausea and vomiting
• Numbness
• Pain and swelling at site of bite
• Paralysis
• Shock
• Slurred speech
• Swallowing difficulty
• Swelling of tongue and throat
• Weakness
• Skin color changes
• Skin tissue damage
• Stomach or abdominal pain
• Weak pulse

(Heller J. L. 2014)

Causes

Figure 3 : A snake
Source - doowansnewsandevents.wordpress.com

Venomous snake bites include bites by any of the following:

• Cobra
• Copperhead
• Coral snake
• Cottonmouth (water moccasin)
• Rattlesnake
• Various snakes found at zoos

(Heller J. L. 2014)

Investigations

Assessment of snake bites are usually done as clinical assessment.

Rapid clinical assessment 

Maintain and clear the airway, ventilate with Ambu bag and mask or ET, Establish IV access, infuse normal saline and check BP.

Examination of bitten part 

Extent of swelling, tenderness, local lymph node enlargement, blistering

General examination 

Pulse rate and BP, skin and mucus membrane for signs of internal bleeding, abdominal tenderness, loin pain and tenderness.

Examine for neurotoxic envenoming

Early external ophthalmoplegia, motor cranial nerves examination and broken neck signs.

Investigations and laboratory tests (20WBCT and other blood tests) 

To look for evidence of bleeding, problems in the blood clotting system, kidney problems, or muscle death.

Identify the snake

(Heller J. L. 2014)

Stepwise Management

First Aid

-       Keep the person calm. Reassure them that bites can be effectively treated in an               emergency room.

-       Restrict movement, and keep the affected area below heart level to reduce the flow         of venom.

-       Remove any rings or constricting items.

-       If the snake was venomous the area of the bite begins to swell and change color.

-       Monitor the person's vital signs (temperature, pulse, respiration, and blood pressure)

-       If there are signs of shock, lay the person flat, raise the feet about a foot, and cover         the person with a blanket.

Do not,

-       Allow the person to become over-exerted.

-       Apply a tourniquet.

-       Apply cold compresses to a snake bite.

-       Cut into a snake bite with a knife or razor.

-       Try to suck out the venom by mouth.

-       Give the person stimulants or pain medications unless a doctor tells you to do so.

-       Give the person anything by mouth.

-       Raise the site of the bite above the level of the person's heart.

(Heller J. L. 2014)

• Check for evidence of fang marks or local trauma in the area of the bite.
• Different kinds of antivenom exist for different species of snakes that are venomous.

(Balentine J. R. 2014)

Acute Renal Failure

Presentation

Acute renal diseases are of 3 types. They are:

-       Pre-renal ARF

-       Intrinsic renal ARF

-       Post-renal ARF

Symptoms of ARF:

• Fluid retention, causing swelling legs, ankles or feet
• Confusion
• Reduced alertness
• Nausea
• Dry mouth
• Fatigue
• Pale skin color
• Disturbances in blood flow in the body
• Decreased urine output
• Drowsiness
• Shortness of breath
• Confusion
• Seizures or coma in severe cases
• Chest pain or pressure

(Mayoclinic. 2012) & (Davita)

Causes

Figure 1 : Causes of acute renal failure

Source - acner.org

Acute kidney failure can occur:

-       Due to impaired blood flow to your kidneys

-       Damage to the kidneys

-       Urine blockage in the kidneys

Pre-renal ARF 

Impaired blood flow to the kidneys

Diseases and conditions that may slow the blood flow to the kidneys include:

-       Blood or fluid loss

-       Blood pressure medications

-       Heart attack

-       Heart disease

-       Infection

-       Liver failure

-       Use of aspirin, ibuprofen, naproxen, or related drugs

-       Severe allergic reaction (anaphylaxis)

-       Severe burns

-       Severe dehydration

Intrinsic ARF 

Damage to the kidneys

Diseases and conditions that may damage the kidneys include:

-       Formation of thrombus in the veins and arteries in and around the kidneys

-       Cholesterol deposits in the vessels of kidneys

-       Glomerulonephritis

-       Hemolytic uremic syndrome - a condition of premature destruction of red blood cells

-       Infection

-       Lupus

-       Medications used to treat osteoporosis and high blood calcium levels (Chemotherapy         drugs, antibiotics, dyes used during imaging tests and Zoledronic acid).

-       Multiple myeloma

-       Scleroderma

-       Thrombotic thrombocytopenic purpura (TTP)

-       Toxins, such as alcohol, heavy metals and cocaine

-       Vasculitis

Post-renal ARF

Urine blockage in the kidneys

Urine blockage can occur when the ureters become blocked. Diseases and conditions of urinary obstructions include:

-       Bladder cancer

-       Blood clots in the urinary tract

-       Cervical cancer

-       Colon cancer

-       Enlarged prostate

-       Kidney stones

-       Nerve damage involving the nerves that control the bladder

-       Prostate cancer

(Mayoclinic. 2012)

Investigations

• Urine output measurements
• Imaging test such as ultrasound and computerized tomography (CT)
• Removing a sample of kidney tissue for testing
• BUN
• Creatinine clearance
• Serum creatinine
• Serum potassium
• Urinalysis

(Mayo Clinic. 2012) & (Silberberg C. 2014)

Stepwise Management

• Treatment should be focused on the underlying cause of the kidney failure.
• The illness or injury that originally damaged the kidneys should be identified because the treatment options will depend on the cause of the kidney failure.
• Treatment of the complications until the kidneys recover.
• Fluid balance in blood

             - If the acute kidney failure is caused by a lack of fluids in the blood, intravenous                fluids should be administered.

  - If it is caused by excess fluid, leading to edema in the arms and legs administer diuretics to expel extra fluids.

• Medications to control blood potassium.

If the kidneys aren't properly filtering potassium from the blood, administer calcium, glucose or sodium polystyrene sulfonate to prevent hyperkalemia. Hyperkalemia can also cause arrhythmias and muscle weakness.

•        Medications to restore blood calcium levels.

If the patient is having hypocalcaemia administer a calcium infusion.

•        Dialysis

If toxins or excess potassium build up in the blood they are removed using dialysis.

(Mayoclinic. 2012)

Figure 2 : Dialysis
Source - www.nocturnaldialysis.org