July 9 talk by Dr. Thompson, Hospitalist, on common pages and how to react to them.

1. Ward Survival Skills
July 2018

2. • Hypertensive Urgency and Emergency
• Chest Pain
• Pain
• Leaving AMA
• Electrolyte replacement
• AMS/Delirium
• Nausea/Vomiting

3. “Doctor, Ms. Jones has a blood pressure of 190/100, what
would you like to do?”
• Why are the nurses calling you with this?
• What do you want to know right now from the nurse in order to
triage this call?
• What do you want to review in the chart to help you decide what to
do?

4. Hypertensive Emergency
• Acutely progressive end organ damage
• No strict BP definition but usually >180 or DBP
>110-120. Exceptions: Eclampsia, sympathetic
crisis, PRES and drugs.
• Uncommon, 1-2 % of patients with HTN
• Non-compliance, African, elderly, male.
• Street drugs.

5. Treatment
• Medications are specific to the end organ damage.
• Goal 10-20% decrease in blood pressure within first
hour and 25% decrease in first 24 hours.

6. Medications
• Nicardipine-IV CCB. Onset 5-10 min. Duration is 30
min but may last 4 hr.
• Esmolol-Cardioselective IV beta blocker, onset 1-2
min. Duration 10-30 min.
• Labetalol-combined alpha and beta blocker. Onset
5-10 min. Duration 3-6 hours.
• Nitroglycerin onset 2-5 min, Duration 5-10min.
• Diuretics variable onset and duration. Benzo’s.
Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42:1206.
Marik PE, Varon J. Hypertensive crises: Challenges and management. Chest 2007; 131:1949.

7. Hypertensive Urgency
or severe asymptomatic hypertension
• Defined as SBP>180 or Diastolic >110-120.
• No evidence of acutely progressive end organ
damage
• Work up includes careful history and ruling
out HTN emergency.
• Common!
• Use oral route if at all possible. Decrease BP
over hours to days.

8. • restart oral medications
• increase dose of current oral medication
• One time dose of short acting agents such as
captopril, labetalol, or clonidine followed by
several hours of observation. Goal <180/110.
• Re-take BP, let the patient relax in a quiet
room. Treat pain, anxiety, withdrawal.
Handler, Joel. Hypertensive Urgency-2006
ESH/European Society of Cardiology (ESC): Guidelines for the
management of arterial hypertension (2013)

9. Hypertensive Urgency vs Emergency
• SBP> 180 DBP >110-120
• IV meds, titrate to decrease in
MAP 10% in the first hour, 25%
by 24 hours.
• Common! No evidence of acute
end organ damage.
• Use oral route if at all possible.
Decrease BP over hours to days.
• Uncommon
• Both
• Hypertensive emergency
• Urgency
• Urgency
• Emergency

10. Quiz time for seniors!
• Acute MI
• Acute pulmonary edema/acute
systolic heart failure
• Acute Ischemic CVA, SAH, ICH
• Acute aortic dissection
• Sympathetic crisis,
Pheocromocytoma
• Cocaine, meth, PCP.
• Eclampsia
• Nitro gtt, esmolol
• Nitro, diuretic. Avoid Beta and
calcium channel
• Nicardipine, labetalol.
• Esmolol, labetalol and then if HR
< 60 and BP >120 add what?
• Phenoxybenzamine, nicardipine
• Benzodiazepines, nicardipine.
• Hydralazine, labetalol

11. “Unfortunately, the term urgency has led to overly
aggressive management of many patients with
severe, uncomplicated hypertension. Aggressive
dosing with intravenous drugs or even oral agents,
to rapidly lower BP is not without risk.”
Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure. Hypertension 2003; 42:1206.

12. My fashion.
• I do not use hydralazine, not ever in the IV form.
• I use the meds they are on, addnl dose.
• I will give labetalol if oral route not available 10-20mg IV push, IV
metoprolol as well.
• Amlodipine 5-10mg po, love it!
• Clonidine 0.1 mg po X 1, may repeat.
• Treat pain, treat anxiety, treat withdrawal.

13. “Doctor, Ms. Jones rates her chest pain as
4/10. What would you like to do?”
• What do you want to know right now from the nurse in order to
triage this call?
• What do you want to review in the chart to help you decide what to
do?

14. Chest pain-crosscover
• Full set of vitals and EKG now.
• See the patient. Focused history and exam. CVD risk factors? Reason for
admission?
• Determine need for further w/up: labs-including serial trop, serial EKG,
chest x-ray. Discuss with your senior/attending.
-ACS or angina, PE, PTX, PNA, dissection, anxiety, GERD,
costochondritis, Zoster, anxiety.
-Risk stratify and determine need for further imaging, work up and
transfer if appropriate.
-ASA appropriate? Nitrate appropriate?

15. Doctor Ms. Jones has 8/10 back pain. Only
medication that works for her starts with a “D”.
Please advise.

16. Pain
• Pain Policy
• Cancer vs non-cancer pain
• Acute vs chronic pain
• Abdominal pain and chest pain-special cases that require more
thought.
• Availability of oral route
• Set expectations on admission

17. Pain-Quiz
• MSK pain, kidney stones, acute LBP
• Chronic low back pain
• Chronic pain taking narcotics at
baseline
• Acute pain on narcotics at baseline
with oral route available.
• Acute pain on narcotics at baseline
with no oral route available.
• Ketorlac, NSAIDS, Tylenol.
• Tylenol, NSAIDS if possible,
duloxetine, tramadol, tizanadine.
• Above plus narcotic w/o escalation
if possible
• Increase dose or frequency of oral
narcotic.
• IV morphine or hydromorphone.

18. The special case of methadone
maintenance….
• Treat pain and methadone
dosing separately.
• Dose should be verified with THS
or other agency within 24 hours,
you can ask social work or
nursing or pharmacy to help you
with this.
• Scheduled Tylenol, ketorolac if
possible, NSAIDS, orals if at all
possible.
Ms Jones is admitted with abscess
and cellulitis. She takes 75 of
methadone a day. You can not verify
dose.
-20mg po methadone is given q
day until dose able to be
verified.
-Scheduled Acetaminophen,
consider oral narcotic if
indicated.
-Oxycodone 10-15 mg q 4. With
discussion: no IV pain
medications and dose will be
titrated down prior to discharge.

19. “Doctor Ms. Jones wants to leave AMA!”
• Review the chart to ensure no issues with capacity.
• See the patient and attempt to resolve situation with in the scope of
your abilities.
• If patient decides to leave…
• Explain consequences and review/sign AMA form.
• Complete med recon and give RX if possible. No controlled substances.
• Advise appropriate follow up
• DOCUMENT the interaction.

20. Capacity
• Ability to express a choice, choice is consistent
• Ability to understand the information-Tell me what you know about
your health problem.
• Ability to appreciate the significance of the information-Tell me what
you think will happen or may happen if you do not get trxt?
• Ability to manipulate the information-has a rational approach to the
decision.

21. Who can leave and who can go…
• Acutely intoxicated
• Acute ETOH withdrawal
• Withdrawal from heroin
• Suicidal
• Demented patient
• Schizophrenic patient who is homeless

22. The perfect AMA
Discuss recommended treatment and options
Go over specific risks associated with refusal
Ask patient to explain diagnosis and consequences
Evaluate the rational for leaving
Discuss follow up and option to return to the hospital
Notify primary, family friends if possible
Document!

23. “ Doctor, Ms. Jones is agitated, she won’t stay in
bed. I need an order for restraints.”
• Information from nursing-new or ongoing? Somnolent or altered?
Pain? Urinary retention? Meds? Full set of vitals now.
• See the patient, consider full set of labs and infectious w/up, ABG,
ekg, imaging as appropriate.
• Chart review/sign out. Medication administration. COPD? OSA?
Obese? New AKI or liver failure changing metabolism of drugs.
• Assess for C02 narcosis, infection, untreated pain, urinary retention.
Neuro exam-CT head if focal, could this be sepsis? D/c offending meds
if possible.

24. What meds should I stop in the newly
delirious patient?
• Fluroquinolones
• Indomethacin
• Ranitidine
• Narcotics
• Scopolamine
• Diphenhydramine
• Promethazine
• Clonidine
• Cyclobenzaprine
• Levo-dopa/benztropine
• Metoclopramide
• Lorazepam
• Baclofen
• Prednisone
• Hydroxyzine
• Dicyclomine
• Oxybutynin
• Zolpidem

25. Management of delirium
• All anti-psychotics carry an increased risk of CV mortality, especially in
dementia. Use order set. EKG to check qTC.
• Restraints-attempt to discuss with family, even if it is at 2am.
• AVOID anti-psychotics
• AVOID benzodiazepines unless seizing or ETOH withdrawal,
parkinsons
• Meds, meds, meds.
• Consult to pharmacy or just a discussion by phone is VERY helpful.
• Use delirium order set, consider Ramelteon/melatonin, early
mobilization.

26. Electrolyte replacement
• Try and replete oral over IV if at all possible.
• Potassium-IV repletion use order set. Oral repletion consider 40 meq
po will raise K by 0.4. Careful with kidney injury, DKA.
• Phosphorous-careful with low phos. Malnutrition, refeeding
syndrome, TPN. Oral K phos or IV NaPhos 15-30mmol for levels <2.

27. Hypomagnesemia
• each 1 gram IV will raise serum level by 0.1-0.2.
• Oral and IV if possible
• Mag <1, 4-8 grams IV
• Mag 1-1.5, 2-4 grams IV
• Mag 1.6-1.9, 1-2 grams IV

28. Nausea and Vomiting-Name the meds with
the black box warning!
• Ondansetron
• Metoclopramide
• Prochlorperazine
• Promethazine Hint: why do we use
this IM, Rectal or oral only?
• Steroids-dexamethasone
• Lorazepam
• Scopolamine
• constipation, qT, serotonin
syndrome.
• Tardive dyskinesia, Beers criteria.
Do not use longer than 12 weeks.
• Increased risk of death with
elderly/dementia, confusion.
• Severe tissue injury and necrosis,
respiratory depression age <2.

29. Seizures in the hospitalized patient
• ABC’s and check blood sugar, ekg, cardiac monitor. Labs including
AED levels. ABG. In the ED: toxicology, ETOH, urine preg. CT head
when able.
• IV lorazepam 0.1mg/kg for 4 mg max /dose. 8-10 mg Max total dose.
or IV diazepam, glucose with thiamine. Midazolam IM as well. Rectal
diazepam.
• IV fosphenytoin 20 PE/kg @150PE/min.
American Epilepsy Society Guidelines 2016 PMID 26900382

30. • Use oral meds if you can for severe asymptomatic HTN
• See the patient with chest pain
• 20 mg methadone is a good place to start for the methadone
maintenance patient.
• New Delirium/agitation is urgent and should be seen, think meds and
distinguish between somnolence and delirium.
• Hypomagnesemia can become an unending loop of repletion unless
you replete with oral as well.
• Anti-emetics can cause problems.

31. Thanks for your attention!
Jennifer.thompson@virginiamason.org