Abnormal vital signs

Question 1

Hypotension etiology ddx (thoughts to be running through your head as you are walking to go see the patient)

Answer 1

Overmedication– recent changes in meds?
Hypovolemia: hemmorrhage, dehydration, overdiuresis
Cardiogenic: MI, afib, v-tach, advanced CHF
Obstructive: Large PE, pericardial effusion
Distributive/Vasodilatory
- Sepsis (always note SIRS cirteria)
- Anaphylaxis (angioedea? uvular edema? hives?)
- Drug reactions? check MAR
- endocrine (rare): adrenal insuff, myxdema coma?
- Neurogenic

NOTE: you will always get full set of vitals, manual BP cuff reading, ask about symptoms, check mentation
NOTE: other card for w/u and management
Think: Exam, labs, +/- IVF with f/u cuff reading, +/- infectious work up

Question 2

Hypotension work-up and management

Answer 2

Go see the patient
Vitals
manual cuff BP reading
ask about symptoms

Exam: Mentation? Cold vs warm? pulse pressure wide v narrow? e/o bleeding? UOP
Labs: End organ dysfunction (trop, lactate, creatinine, urine output). EKG
Consider IVF: know patient hx (CHF, pulm edema)
Reassess BP after fluids
Consider infectious workup (BCx, UCx, CXR)– always in immunocomp patients
MICU/CCU eval if not responding

Question 3

SIRS criteria (basic)

Answer 3

2 or more of the following

T > 38 or < 36
HR > 90bpm
RR > 20 or PaCO2 12k or < 4k or >10% bands

Question 4

HTN urgency vs emergency/malignantHTN

• what are the defining systole/diastoles
• what differentiates the two?
• what are the signs/symps of the differentiating factor?
• what are the inital intervention possibilities?
• what is the goal?

Answer 4

SBP > 180 DBP >120
End organ damage is the key
Pts who are asymptomatic and do not show evidence of end-rogan damage, do NOT require immediate blood pressure lowering.

Evidence
Heart: MI, aortic dissection, acute left ventricular failure, CP, SOB, flash pulm edema
Kidney: AKI. Gross hematuria, oliguria, azotemia
Eyes: Papilledema, retinal hemorrhages, exudates
Brain: HTNive encephalopathy, HA, n/v, irritability, AMS, ICH/SAH, seizures

Treatment

• Increased current HTN meds or give previously written PRNs
• Consider PO hydralazine 10-25mg. Onset 20-30min, duration 2-4h
• Refractory HTN may require gtt and CCU eval
• see pg 10 for other med options

Question 5

Narrow Complex Tachycardia

• 3 reflex moves
• 3 big categories on ddx
• for each, what is the ddx, what is the treatment approach?

Answer 5

3 reflex moves

• EKG and full set of vitals
• Put on tele
• If patient is unstable (hypoTN) –> Get help and consider cardioversion

Sinus Tach

• if unstable, get help, consider cardioversion
• treatment directed at cause, not rate
• DDX: fever/infection/sepsis, PE, ACS, hypovolemia, anemia, anxiety, pain

Paroxysmal SVT (AVRT, AVNRT)

• if unstable, get help, consider cardioversion
• try vagal maneuvers, consider rapid adenosine push with senior

atrial fibrillation or flutter with RVR
- if unstable, get help, consider cardioversion
- consider treating underlying causes (see ablove)
- other treatment options
-- 5-10mg metop IV or 10-15mg dilt IV
-- dilt gtt for goal HR < 120
-- amiodarion loading/gtt 
- transfer to CCU or tele 
\+/- anticoag, usually heparin gtt

Question 6

Wide complex tachycardia

• 3 reflex moves
• If stable, what next?

Answer 6

3 reflex moves

• check pulse. if pulseless –> call code, start ACLS
• all wide complex tach should have senior resident. call senior
• get full set of vitals, EKG, tele

ABCD(dx) + 5 procedures

• get pads on for potential defibrillation
• tele, EKG stat
• oxygen
• IV access
• Dx: Chem, Mg, trops, CKMB, dig levels
• low threshhold for CCU transfer