Primary Care Emergencies

Question 1

What is considered significantly elevated blood pressure?

Answer 1

> = 180/>= 120 mmHg

Question 2

What should be included in the assessment of patients with significantly elevated BP?

Answer 2

acute head injury, general neurologic symptoms, focal neurologic symptoms (stroke), flame hemorrhages/cotton-wool spots/papiledema (hypertensive encephalopathy), nausea/vomiting (increased intracranial pressure), chest discomfort (MI), acute/severe back pain (aortic dissection), dyspnea (pulmonary edema), pregnancy (preeclampsia), use of drugs

Question 3

What tests should be performed in a patient with significantly elevated BP?

Answer 3

ECG, chest x-ray, urinalysis, electrolytes, creatinine, cardiac enzymes, CT or MRI of the brain and/or chest

Question 4

Why should BP be lowered gradual in a hypertensive crisis?

Answer 4

lowering too quickly can lead to ischemic damage in vascular beds that have grown accustomed to the higher BP

Question 5

What is the exception to gradual lowering of BP in a hypertensive emergency?

Answer 5

acute aortic dissection - SBP must be lowered to 100-120 mmHg within 20 minutes - treat first with a beta blocker to lower heart rate and a vasodilator to quickly achieve goal BP

Question 6

What should be the target for treatment of hypertensive emergencies?

Answer 6

gradually reduce mean arterial pressure by 10-20% in the first hour and by a further 5-15% in the next 23 hours

Question 7

What is anaphylaxis?

Answer 7

acute, potentially lethal, multisystem syndrome resulting from sudden release of mast cell- and basophil-derived mediators into the circulation - most often results from immunologic reactions to food, medications, and insect stings

Question 8

What is the most common mechanism responsible for analphylaxis?

Answer 8

antigen/allergen interacting with an allergen-specific immunoglobulin E (IgE) bound to the Fc-epsilon-RI receptor on mast cells and/or basophils - leads to a “chain reaction” of allergic inflammation

Question 9

What are potential causes of nonimmunologic anaphylaxis?

Answer 9

activation of complement, direct activation of mast cells/basophils by vancomycin (“red man syndrome”), use of opiate medications, cold urticaria, oversulfated chondroitin sulfate

Question 10

What are the chemical mediators of anaphylaxis?

Answer 10

degranulation of mast cells/basophils results in systemic release of biochemical inflammatory mediators and chemotactic substances: histamine, tryptase, chymase, heparine, tumor necrosis factor, interleukin, prostaglandin, platelet-activating factor

Question 11

What are the causes of death in anaphylaxis?

Answer 11

circulatory collapse or respiratory arrest due to shock to heart, lungs, and vasculature - peripheral tissues continue to consume oxygen at relatively high rates leading to anaerobic metabolism and end-organ damage

Question 12

What are signs and symptoms of anaphylaxis?

Answer 12

angioedema, itching, urticaria, SOB, stridor, syncope, rash, anxiety, periorbital edema

Question 13

When should you refer to a specialist in a case of anaphylaxis?

Answer 13

all cases of anaphylaxis should be referred to a board-certified allergy specialist in confirmed or suspected anaphylaxis

Question 14

What should be included in the history for anaphylaxis?

Answer 14

24-hour period before the onset of symptoms (particularly the 1-2 hours immediately preceding symptoms onset) - exposures, chronology of events, baseline health and activities, medications

Question 15

What is the treatment for anaphylaxis?

Answer 15

epinephrine IM

Question 16

What level of serum tryptase confirms a diagnosis of anaphylaxis?

Answer 16

> 11.4 ng/mL or elevated by at least 20% above baseline plus 2 ng/mL - blood samples should be obtained 15 minutes to 3 hours after symptom onset

Question 17

What are the diagnostic criteria for anaphylaxis?

Answer 17

any one of the following: (1) acute onset involving skin or mucosa and respiratory compromise or reduced BP, (2) 2 or more of the following after exposure to a LIKELY allergen: skin/mucosal involvement, respiratory compromise, reduced BP, persistent GI symptoms, (3) reduced BP (SBP < 90 or > 30% decrease from baseline) after exposure to KNOWN allergen