223 ) A 38 year old obese African American man presented to the emergency department with headache, blurred vision and weakness. His past medical history was unremarkable. He smoked about 1 pack per day for 20 years. On examination, this patient’s blood pressure was 210/140 mmHg, heart rate 98/min, RR 20/min and temperature 98.6 F. He is alert, awake and oriented. Physical examination is unremarkable. There are neurological deficits. Laboratory investigations showed Hemoglobin 8.2 g/dl, White cell count 10k/µl, Platelets 97000/µl, Sodium 140meq/L, Potassium 4.0meq/L, Bicarbonate 24meq/L, BUN 34 and Creatinine 3.2mg% . Further investigations included a Lactic dehydrogenase which was elevated at 900U/L and a reticulocyte count of 7.0% . A periphreral smear is shown below :
The most appropriate next step in managing this patient:
A) Fresh frozen plasma
B) Intravenous Labetalol
C) Plasmapheresis
D) Intravenous Nitroprusside
E) Hemodialysis
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I would go with “C”
B
This patient seems to have end organ damage from hypertensive emergency.. is it D?
D) Intravenous Nitroprusside
B) IV Labetalol- used for hypertensive emergencies with headache, blurred vision and weakness. DOC Hypert. Em with coronary ischemia is sod. nitroprusside and should not be used with hypertensive encephalopathy because it increases ICP.
B….
Labetalol provides a steady consistent drop in blood pressure without compromising cerebral blood flow. Labetalol is frequently used as initial therapy. Because of nonselective beta-blocking properties, it should be avoided in severe reactive airways disease and cardiogenic shock.
Nitroglycerin has been used to provide a rapid reduction in blood pressure complicating myocardial ischemia. The reduction in blood pressure may be severe and can cause further complications due to venodilatory effects in volume-contracted individuals. Nitroprusside and hydralazine pose a theoretical risk of intracranial shunting of blood. Thus, these agents should be avoided in patients suspected of having increased intracranial pressure (ICP) because they may cause intracerebral shunting of blood, which increases ICP. An increasing number of authorities are considering labetalol, nifedipine, and esmolol as the preferred initial agent.
TTP
plasmapheresis.
B….. there are neurological deficit which makes the complications of microangiopathic hemolytic anemia, ICB or ischemic stroke highly suspicious……….therefore Nitropruside is contraindicated, and will go for IV Labetolol.
ANS.B….Malignant HTN should be differentiated from TTP, HUS, DIC & microangiopathic hemolytic anemia, a wide variety of diseases that can resemble the same clinical features.
In this case although he had thrombocytopenia, hemolytic anemia , renal problem & CNS manifestations which can lead to TTP. BUT his HTN suggests that its more of MALINANT HTN features and should be treated emergently with Labetalol (IV) ….
we suspect the patient has ttp next step is to reduce HTN
no fever
patient has hypertensive emergency (hypertensive encephalopathy, microangiopathic hemolytic anemia that is one of the complication of hypertension, renal failure)
The characteristic vascular lesion is fibrinoid necrosis of arterioles and small arteries, which causes the clinical manifestations of end-organ damage. Red blood cells are damaged as they flow through vessels obstructed by fibrin deposition, resulting in microangiopathic hemolytic anemia.
IV labetalol (IV nitroprusside and Iv hydralazine is not given in increase ICP and encephalopathy).
Answe B>http://emedicine.medscape.com/article/241640-overview#aw2aab6b2