Emergency Medicine Lecture Notes

Patient Case Overview

• Patient: 60-year-old male
• Complaints: Generalized tiredness and headache for two days
• Triage: Green, based on SOAD criteria (GCS, BP, Respiratory Rate)
• Initial Assessment:
  • Conscious, oriented, obeying commands
  • Airway patent, no gurgling or secretions
  • Breathing rate 24/min, saturation 95% on room air
  • Circulation: HR 90 bpm, BP 200/110 mmHg, palpable peripheral pulses
  • Disability: GCS 15/15, pupils reacting equally to light
  • Exposure: GRBS 190 mg/dL, normal temperature, pain score 4/10

Interventions

• IV Cannulas: Inserted
• Medication: Injection PCM 1g IV stat
• ECG: Normal sinus rhythm, HR 85 bpm, no acute changes
• VBG: pH 7.42, PCO2 43, Bicarbonate 23, Potassium 3.8, Creatinine 1.2

Medical History

• Alcohol Use: Described details on alcoholism effects
• Symptoms: Snoring, choking during sleep, personality changes
• Indication of: Possible Obstructive Sleep Apnea Syndrome
• Exclusions: No signs of dangerous headache, CVA, MI, aortic dissection
• Past Episodes: Elevated BP, started on Ayurvedic medications

Examination Findings

• General: Conscious, cooperative, well-built, BMI 32 (Grade 2 obesity)
• Systemic:
  • CNS: GCS 15/15, power 5/5
  • Respiratory: Normal vesicular sounds
  • Cardiovascular: S1, S2 present, no murmurs
  • Abdomen: Soft, non-tender, bowel sounds present

Provisional Diagnosis

• Hypertension: Asymptomatic markedly elevated BP (formerly hypertensive urgency)
• Approach: Based on Indian Endocrine Society guidelines

Management Guidelines in ER

• Hypertensive Emergency: BP >180/120 with organ damage
• Hypertensive Urgency: BP 160-180/100-120 without organ damage
• Treatment:
  • Emergency: Immediate reduction by 15-20% in first hour
  • Urgency: Gradual reduction over 24 hours
  • Medications: Start oral antihypertensives
    • Options: ACE inhibitors, ARBs, calcium channel blockers, diuretics

Case Discussion Points

• Assessment of Long-term Hypertension:
  • ECG for LVH, echo for cardiac assessment
  • Eye examination for retinal changes
  • Urine analysis for proteinuria
• Adjustment of Medications: Based on renal function and contraindications
• Salt Management: Restrict additional salt, balance intake considering renal and cardiac status
• Potassium Management: Monitor and correct low levels

Final Management and Follow-up

• Sleep Study: Diagnosed Obstructive Sleep Apnea (OSA), started CPAP
• Medication: Continued with ARB, managed BP and sleep quality
• Monitoring: Regular follow-up and adjustments as necessary

Important Considerations

• Secondary Hypertension Causes: Rule out endocrine/renal causes
• Beta Blocker Use: Avoid in certain conditions like pheochromocytoma
• Guidelines: Follow European Society of Cardiology and Indian Society of Hypertension for BP management
• Screening for Conditions: Consider primary hyperaldosteronism, Cushing's syndrome with distinct clinical features