POTD: Asymptomatic Hypertension in the ED

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Clinical Scenario: 58 yo F with no significant PMH presents to the ED for high blood pressure.  She reports having a BP of 190/110 at the pharmacy and came right to the ED.  She denies HA, vision changes, chest pain, dyspnea, and oliguria.  She last saw her PMD for her annual checkup many months ago, noted her BP was mildly elevated at that time, no medications were started then, and she is not currently taking any medications other than her vitamins.  

Question: What is your workup for her?  Should you go beyond an H&P?  Do you start her on medications?

As per ACEP Clinical Policy from 2013, the term asymptomatic markedly elevated blood pressure includes the frequently used terms of asymptomatic hypertension and hypertensive urgency, which described markedly elevated high blood pressure without clinical evidence of acute end organ injury.

Under their 2013 policy, Level C recommendation is that: asymptomatic markedly elevated blood pressure in ED patients do not require routine screening for acute target organ injury (such as serum Cr, UA, EKG). Though in select patients, like those with poor follow-up, a screening for elevated Cr may identify kidney injury that changes disposition like admission.

Another Level C recommendation is that routine ED medical intervention is not required in these asymptomatic markedly elevated blood pressure patients.  Consensus recommendation is that in select patients, like those with poor follow up, the ED physician may treat the BP in the ED and/or start long term therapy for BP control.  Consensus recommendation is that patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up.

**So when do you treat the number acutely?  Treat the clinical picture, not the elevated BP reading**

 

Want to read more?

https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=429&inittopicdload=1

http://www.emdocs.net/em3am-asymptomatic-hypertension/

http://epmonthly.com/article/dont-let-hypertension-stress/

https://www.mdedge.com/emed-journal/article/114826/hematology/hypertension-ed

Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM. Clinical policy: Critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med 2013;62(1):59–68.  https://www.ncbi.nlm.nih.gov/pubmed/23842053

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POTD: Euglycemic DKA

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Today’s POTD comes from Dr. Buckingham.  Her clinical question: Can a patient present as a first time diabetic with euglycemic DKA? Hmmm... Let’s break question down.  

How do you diagnose diabetes in a patient?

  • Symptomatic hyperglycemia with classic symptoms of thirst, polyuria, weight loss with a random BGM≥200mg/dL
  • Fasting plasma glucose ≥126 mg/dL
  • Oral glucose tolerance test with two hour plasma glucose ≥200 mg/dL
  • HbA1C values ≥6.5%

 

What is euglycemic DKA?

Just as the name states, euglycemic DKA is diabetic ketoacidosis without the hyperglycemia.  Patients will have the serum/urine ketones and anion gap metabolic acidosis of DKA while glucose levels are normal/mildly elevated (<200mg/dL).  Patients that present with euglycemic DKA are usually those with poor carbohydrate intake, adequate hydration, use of insulin, alcohol intake, or use of sodium-glucose co-transporter 2 (SGLT2) inhibitors [Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance)].  Euglycemic DKA occurs more often in type 1 but can also occur in type 2 diabetes, and the most common symptom is vomiting.

**Check labs for patients with concerning story of DM, poor carbohydrate intake and/or taking SGLT2 inhibitor, c/o nausea/vomiting/fatigue/SOB**

 

So can someone present with no prior hx of diabetes and have euglycemic DKA?

Maybe, if they have been having poor carbohydrate intake but tolerating fluids.  However, also consider a broader differential diagnosis such as starvation ketoacidosis, alcoholic ketoacidosis, lactic acidosis, and drug toxicity.

 

Want to read more?

http://care.diabetesjournals.org/content/38/9/1638

https://emergencymedicinecases.com/euglycemic-dka/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4488998/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5592704/

http://rebelem.com/euglycemic-dka-not-myth/

https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-diabetes-mellitus-in-adults

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POTD: Neutropenic Fever Part II

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Clinical Scenario Continued: Your febrile neutropenic patient has been started on antibiotics with blood cultures sent and you are pending a return page from her oncologist.  The patient starts asking you if you could discharge her home because she feels a lot better and does not want to be in the hospital.  Her vital signs have improved and she is no longer tachycardic or febrile, she tolerated PO in the department and ambulated.  Your lab work and chest x-ray have been unremarkable other than neutropenia.
 
Question 1: Are neutropenic fever patients ever considered low risk?
Under the IDSA guidelines, most experts consider high risk patients to be those who have anticipated prolonged and profound neutropenia (>7 days with ANC≤100mm3 after cytotoxic chemotherapy), and/or have comorbid medical conditions like hypotension, pneumonia, neurological changes, or new abdominal pain.  Low risk patients are those whose neutropenic periods are anticipated to be brief (≤7 days) with few or no co-morbidities.
 
Question 2: Should you discharge a low-risk neutropenic fever patient home from the ED with oral antibiotics?
There are validated risk-stratification tools that help identify low-risk febrile neutropenic patients that could be sent home on oral antibiotics, used in the clinic and inpatient settings, two of which are the Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE).  You can find these calculators here:
There has been a recent retrospective study on these two tools on inpatients by Coyne et al. 2017: http://www.annemergmed.com/article/S0196-0644(16)31352-X/abstract
The CINSE was found to be highly specific in identifying low-risk patients (98.3% specific with 95% CI 89.7-99.9%) while MASCC was found to be much less specific (54.2% with 95% CI 40.8-67.1%).  However, this a retrospective study on inpatients and whether this can be extrapolated to discharged patients on oral antibiotics from the ED is still a question.  Prospective data is needed.
You can find the EM:RAP commentary on this study here: http://www.annemergmed.com/article/S0196-0644(17)30416-X/pdf
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